ACH-Recurring Payment

Legal Business Name

Federal Tax ID #

Mailing Address

Email Address (for confirmation)

Primary Contact

Title

Owner's Legal Name

Address

Phone Number

FAX Number

Phone Number

FAX Number

Payment Type

Recurring payment

One time payment

I hereby authorize C&S Associates, Inc. dba NCS Credit to electronically debit the above account. Notification to terminate must be made at least 10 days prior to the draw date. This authorization will automatically terminate when the agreed amount is paid in full. Non-sufficient funds are subject to additional fees.

Electronic Signature Message

Account Owner Signature

Name

Bank Name

Transit/Routing Number

Account Number

Account Name

Joint Signature, if applicable

Date

Title

City

State

Joint Account?

Yes

Type

Business Account

Personal Account

Checking

Savings

Cancel