Billing Information Form

Today's Date * +

Company Name

Email Address

Billing Information

What do you want to use in billing?

Checking Account (ACH)

Credit/Debit Card (3% processing fee applied)

Name on Card

Credit/Debit Card Type

Credit/Debit Card Number

Expiration Date (mm/yy)

Do you authorize us to charge your card based upon verified savings that we achieve on your behalf, as outlined in your signed Savings Agreement?

Yes

There will be 3% processing fee when you pay using credit card. Agree?

Yes

First Name

Last Name

Billing Street Address (Address in your Voided Check if ACH)

City

State

Zip Code

Phone Number

Routing #

Account #