Merchant agrees to the terms set forth in this Electronic Credit
and Payment Authorization form dated as
of 12/18/2017, submitted by (“Merchant”) The Preferred Prepaid’s Merchant
and (iv) applicable federal regulations governing Automated Clearing House (“ACH”) transactions,
I (we) do hereby authorize THE PREFERRED PREPAID, epay (a Division of Euronet Worldwide, Inc),
and Emida (Debisys Inc) or any partner or subsidiary or affiliates of The Preferred
Prepaid (collectively referred to as “THE PREFERRED PREPAID” for the purposes of this ACH Authorization) to
initiate debit and credit entries to the account specified below for obligations owing from
I certify under penalty of perjury that am a duly authorized as a check signer on the account
identified below and am authorized to provide all relevant consents and representations contained
in this ACH Authorization, as evidenced by my signature below or by pressing the agreement button.
In the event that THE PREFERRED PREPAID incurs any charges due to failure of an ACH debit to properly
process to Merchant’s account specified above (after several attempts by The Preferred Prepaid), or in
the event that such account does not have sufficient funds to permit the ACH debit to go through, I (we)
hereby grant THE PREFERRED PREPAID the authority to debit the account for all such charges and expenses
incurred together with a $30 administrative fee per failed ACH. This authorization is to remain in full
force and effect until THE PREFERRED PREPAID has received written notification from me or another duly
authorized representative of Merchant of it’s the termination hereof in such time and in such manner
as to afford THE PREFERRED PREPAID and its partners, a reasonable opportunity to act on it.
All information gathered in this form will be kept strictly confidential
The data remains confidential;
The information you provide will be kept in a secure environment.
The privacy of the information you provide will be safeguarded and only disclosed if required by law.