KwickPOS SaaS ACH Authorization Form
ACH=Automated Clearing House
Authorization Agreement
*
This is to acknowledge that I am an authorized signer on the bank account listed below and am a duly authorized representative/officer/owner of the company named on this document. KwickPOS is hereby authorized to initiate debit entries to the bank accountidentified below and the bank is authorized to debit such account. KwickPOSwill debit the referenced checking account monthly in the amount of my Company'sinvoice for such services provided and/or billed by KwickPOS. This billing will be deducted between the 1st and 10th day of each month to pay the previous months balance due in full. A copied or voided check attached must be attached or provided with this completed form. This authority is to remain in full force until this authorization is cancelled in writing with a minimum 15 business day notice. If an authorized ACH DEBIT is not paid by your financial institution due to non- sufficient funds (NSF), there will be a $35.00 administrative fee assessed, the payment then due must be made prior to the next billing cycle and your auto debit will be cancelled.
Signature
*
Name
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Subscription Start Date
/
Month
/
Day
Year
Date
Monthly Subscription
*
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KwickPOS Main Subscription
$
29.00
KwickPOS Saas Subscription - 2nd+
$
15.00
Quantity
KwickPOS Tablet Subscription
$
15.00
Quantity
KwickPOS Kiosk SaaS Subscription
$
60.00
Quantity
KwickPOS Monthly Gateway Fee
$
60.00
Quantity
KwickPOS Monthly Support Fee
$
60.00
Quantity
Total
$
0.00
Name
*
First Name
Last Name
Email
*
example@example.com
Name(s) on Bank Account (business name if used)
*
Routing Number
*
must be 9 numbers - no spaces
Account Number
*
must be 9-12 numbers - no spaces
Bank Name
*
Bank Branch
*
City, State
Type of Bank Account
*
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
Bank Phone Number
-
Area Code
Phone Number
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