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