Payment eCheck - Las Vegas, Paradise, Henderson

I authorize NetEffect, LLC to initiate either an electronic debit or to create and process a demand draft against my bank account on or after

for the amount of

I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. My account information is as follows:

Invoice Number
Quote Number

Enter the Invoice Number*

Enter the Quote Number*

Bank Information

Bank ABA Routing Number:*

Bank Account Number:*

Bank Account Type:*

By entering my printed name and date below, I am accepting this as my digital signature and authorization to proceed as described above. I also stipulate that I have all necessary authorization from the company from which the debit or draft will be drawn.

Company Name*

Printed name:*

Date Signed:*

Name

This field is for validation purposes and should be left unchanged.