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T3CH WORX > Payment Authorization Form

Payment Authorization Form

Account Holder Information

Are you a new or existing customer?(Required)
Payment Method(Required)

Company Information

Name(Required)

Billing

Billing Address(Required)

Checking / Savings Account

Accepted file types: pdf, jpg, jpeg, png, bmp, gif, Max. file size: 50 MB.
Please upload a photo of a voided check with matching bank account # and routing #.

Credit Card

Type of Card(Required)
Cardholder Name(Required)

Authorization

Authorization(Required)
I hereby authorize T3CH WORX to initiate debits to my account indicated above for the purpose of satisfying any outstanding invoices. I authorize the depository financial institution named above to process said entries. I understand that amounts are variable with each billing cycle. I waive my right to receive written notice of varying amounts.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify T3CH WORX in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that T3CH WORX may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
MM slash DD slash YYYY
I understand and agree to the above.(Required)

T3CH WORX

70 N Broad St, Suite T

Winder, GA 30680

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