ACH Payment Authorization
Authorize a one-time ACH payment.
This authorization only applies to the payment described below.
Customer Information
Customer / Company Name
*
Phone Number
*
Email Address
*
Payment Information
Invoice Number
N/A
Payment Amount
$0.00
Authorization Agreement
By signing below, I authorize Ged’s Floor Store to initiate a one-time ACH debit in the amount listed above for the invoice, order, or transaction identified in this form.
I certify that I am an authorized signer on the bank account listed above. I understand that ACH payments are governed by applicable banking rules and NACHA regulations.
Returned or rejected ACH payments may result in additional fees, collection activity, or legal action as permitted by law.
Electronic Signature
Full Legal Name
*
Date
*
I agree that checking this box and submitting this form constitutes my electronic signature and authorization for this ACH payment.
Authorize ACH Payment