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Direct Payment Application

 
 
 


    Authorization for Direct Payments via ACH/Credit Card

    I, as a duly authorized representative of the Client, authorize Mind-Storm, to electronically debit the below account and/or process credit card in the amounts and at the times set forth in executed Statement of Work, and, if necessary, to electronically credit that account to correct erroneous debits.

    Client information:

    Full Name (required)

    Your Email (required)

    Company (required)

    Phone Number(required)

    Tax ID

    Bank information:

    Bank Name

    Bank City and State

    Bank Account Number

    Bank Routing Number

    Credit Card Number:

    Credit Card Expiration Date:

    Credit Card CVV number:

    It is acknowledged that this authorization will remain in full force and effect for the duration of the Term or until revoked by the Client in a writing delivered in accord with the Agreement.

    Signature below


    Street address:

    Address:

    City:

    State/ Province

    Zipcode

    Country