Subido por Luis Romaguera

AUTOMATIC DEBIT FORM

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AUTOMATIC DEBIT/ CREDIT CARD AUTORIZATION FORM
I (we) authorize Neptuno Media, Inc., hereinafter called COMPANY, to initiate debit entries to my (our)
checking/savings account (circle one) indicated below at the depository financial institution named below,
hereinafter called DEPOSITORY, and to debit the same to such account. I authorize to debit the full amount of
the monthly Invoice. I (we) acknowledge that the origination of ACH transactions to my (our) account must
comply with the provisions of US law.
Bank Information:
Customer Name (As in Bank Statement)
Customer ID Number
Bank Name
Branch
City
State
Zip


Checking
Savings
Routing Number
Account Number
Contact Person to receive payments notifications:
Email:
To be debited of my Bank Account/Credit Card the
□ 5 □ 10 □ 15 of each month.
Credit Card Information:
___VISA ___MC ___ AMEX ___ DISCOVER Card Number:_____________________________________
Expiration Date :___/___/___ CVV:_____ Name(as is in the Card) _________________________________
Address as appears in the Account Statement:_______________________________________________
Name
Position
Date
Signature
NOTE: All written debit authorization must provide that the receiver may evoke the authorization only by
notifying the originator in the manner specified on the authorization form. Any change in the bank
account/Credit Card number should be notified within 30 days of anticipation and a new form have to be filled.
This authorization is to remain in full force and effect until COMPANY has received a written notification of
its termination in such time and manner as to afford COMPANY and DEPOSITORY a reasonable opportunity
to act on it. Once the debit is cleared a payment confirmation will be send. It is Clients responsibility to maintain
this information updated.
Form can either be mailed to: Neptuno Networks PO Box 191995 San Juan PR 00919-1995 or
faxed (787) 775-0081 or by email: accounting@neptunopr.com
Rev 06_19
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