ACH Billing Information Form

ACCOUNT INFORMATION
Company Name*
Billing Contact*
Billing Phone*
Billing Email (Primary)*
Billing Email (Secondary)
ACH PAYMENT INFORMATION
Account Type*
Name on Account*
Bank Account Number*
Bank Routing Number*
Bank Name*
Bank City, State*
AUTHORIZATION
Authorization*
- Agreed, Authorized
Acting legally, on behalf of the company, hereby authorize Opus Interactive, Inc. to charge my checking account for balances owing on my account. This authorization will remain in full force and effect until I notify Opus Interactive in writing that I wish to revoke this authorization. If the payment is rejected due to Non Sufficient Funds (NSF), I understand that the company may attempt to process the transaction again within 30 days, and I agree to an additional $35 charge for each attempt that is returned due to NSF, which will be initiated as a separate transaction from the authorized payment. I further agree to provide updated billing and payment information, as necessary, in order to remit payments in a timely manner.

ACCOUNT INFORMATION