ACH Authorization Form

This form submits information through a secure, encrypted database. No data is transmitted through email or other plain-text systems.

Contact Information

Contact First Name:

Contact Email:

Contact Last Name:

Contact Phone:

Customer Account/Bank Information

Business Name:

City:

Business Address:

State:

Business Phone:

ZIP:

Account Holder's Bank Information

Bank Name:

Branch:

ZIP:

State:

Bank Routing Number (9 digits):

Bank Account Number:

Transaction Information

Goods Purchased/Services Rendered:

No. of Transactions: Or Open Ended

One-Time:

Amount of Transaction ($):

Recurring:

Effective Date:

All recurring transactions will be debited on the 1st of every month. If the 1st of the month falls on a non-business day the account will be debited on the first business day following.

Authorization

In exchange for products and/or services listed above the undersigned hereby authorizes ATS Communications, Inc. to electronically draft via the Automated Clearing House system the amount indicated above from the account identified above. This authority will continue until withdrawn in writing by the undersigned account holder. The undersigned hereby certifies that they are duly authorized to execute this form on behalf of the listed business name. I acknowledge that I am subject to a $25 reject fee if items are returned for insufficient funds.

Name/Title:

Date: