Recurring Payment Authorization

Recurring Payment Authorization Form

Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard or American Express Card.

The Benefits of Recurring Payments:

It’s convenient (saving you time and postage)
Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount of changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please note that all credit card transactions are subject to a 3.75% convenience charge. If the ACH option is selected and the bank information is provided, the 3.75% charge is not applicable.

Please complete the information below:

I authorize Aluminum Capping Services Inc., dba Integrity Machine Services to charge my credit card indicated below for the amount indicated below on the date of each month indicated below for payment of my machine lease per the signed lease Agreement.

"*" indicates required fields

Name*

First Last

Recurring Payment Amount ($)*

Recurring Payment Percentage (%)*

Recurring Payment Date (____ of each month)*

Billing Address*

Street Address City State ZIP Code

Phone*

Email*

Payment Type*

Checking / Savings Account

Credit Card

Checking / Savings Account Info

Account Type*

Checking

Savings

Name on Account*

Bank Name*

Account Number*

Bank Routing #*

Bank City*

Bank State*

Credit Card Information

Card Type*

Visa

MasterCard

Amex

Discover

Cardholder Name*

Account Number*

Exp. Date (mm/yyyy)*

CVV Code*

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Aluminum Capping Services Inc., dba Integrity Machine Services in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Aluminum Capping Services Inc., dba Integrity Machine Services may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.