Debit Authorization Form

Please use the form below to create a debit authorization. This will allow us to debit the account of your choosing to pay your invoice. We will email you a confirmation once we receive your submitted form.

Authorization Agreement for Direct Debit – One Account (ACH Debits)

Full Name

Email

I (we) hereby authorize Blackwell Auctions LLC, hereinafter called Company, to initiate debit entries and if necessary, credit entries and adjustments for any debit entries in error to my (our) account;

And the depository named below, hereinafter called Financial Institution, to credit and/or debit the same to such account.

Financial Institution

Transit/ABA No.

Account No.

Account Type:

Checking/Draft

Savings/Share

Please attach voided check

Maximum file size: 314.57MB

This authorization is to remain in full force and effect until Company has received written notification from me (us) of its termination in such manner as to afford Company and Financial Institution a reasonable opportunity to act on it.

Signature

Clear

Date

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