Jazel Recurring Payment Authorization Form

Jazel Recurring Payment Authorization Form – ACH

Schedule your ACH (Automated Clearinghouse) payment to be automatically transferred from your bank
account to Jazel. Recurring payments occur on or shortly after the first of the month unless otherwise
indicated in your agreement(s). One-time payments for set-up fees, partial month site launch prorations or
other requested ad-hoc services will be processed in accordance with the terms outlined in your
agreement(s).

Company Name*
Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Billing Contact Name*
Billing Phone*
Billing/Invoicing Email*

Invoices will be sent to this email address
Account Information
Account Type*
Bank Name*
Branch Address*
City State / Province / Region ZIP / Postal Code
Bank Routing Code
Bank Account Number*
Consent*
The following consent authorizes Jazel, LLC to transfer the payment amount according to the terms outlined in your agreement(s). I certify that I am the authorized user of the bank account listed on this form and that I will not dispute the payment; so long as the transaction corresponds to the terms of our agreement(s). Invoices will be sent electronically and charges will be deducted the same day. I understand that these withdrawals will be made every month throughout the term of the agreement(s) or until I give you written notice to terminate this ACH authorization method. I understand that my election to terminate this ACH transfer may require up to 7-10 banking days to process and become effective.

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Jazel Recurring Payment Authorization Form

Account Information