Recurring Payment Authorization Form

If you would like to enjoy the convenience of automatic recurring billing, simply complete the information section below, submit this form and sign the form on the subsequent page. All requested information is required. Upon approval, we will automatically bill your chosen payment method for the amount indicated in your proposal and your total charges will appear on your monthly credit card or bank statement. You may cancel this automatic billing authorization at any time by contacting us.

Business Name*

Client Name*

First Name Last Name

Email*

Enter Email Confirm Email

Phone*

Payment Details

I prefer eCheck payments

I prefer eCheck payments

Account Type

Routing No.

Account No.

Debit or Credit Card Number

Expiration Month

Expiration Year

Name (as shown on card)*

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Commercial Card

This is a commercial card

Customer Accounting Code

Sales Tax

Consent*

I agree to recurring payments*

I authorize Net Solutions Interactive to initiate either an electronic debit on the card or bank account listed on this form and or to create and process a demand draft against my bank account according to the terms outlined in my proposal.

I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

This payment authorization is to remain in full force and effect. You may cancel this automatic billing authorization at any time by notifying Net Solutions Interactive of its cancellation by sending written notice in such time and in such manner to allow both Net Solutions Interactive and receiving financial institution a reasonable opportunity to act on it.

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Name

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