AUTOMATIC DEBIT/ CREDIT CARD AUTORIZATION FORM I (we) authorize Neptuno Media, Inc., hereinafter called COMPANY, to initiate debit entries to my (our) checking/savings account (circle one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I authorize to debit the full amount of the monthly Invoice. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of US law. Bank Information: Customer Name (As in Bank Statement) Customer ID Number Bank Name Branch City State Zip Checking Savings Routing Number Account Number Contact Person to receive payments notifications: Email: To be debited of my Bank Account/Credit Card the □ 5 □ 10 □ 15 of each month. Credit Card Information: ___VISA ___MC ___ AMEX ___ DISCOVER Card Number:_____________________________________ Expiration Date :___/___/___ CVV:_____ Name(as is in the Card) _________________________________ Address as appears in the Account Statement:_______________________________________________ Name Position Date Signature NOTE: All written debit authorization must provide that the receiver may evoke the authorization only by notifying the originator in the manner specified on the authorization form. Any change in the bank account/Credit Card number should be notified within 30 days of anticipation and a new form have to be filled. This authorization is to remain in full force and effect until COMPANY has received a written notification of its termination in such time and manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. Once the debit is cleared a payment confirmation will be send. It is Clients responsibility to maintain this information updated. Form can either be mailed to: Neptuno Networks PO Box 191995 San Juan PR 00919-1995 or faxed (787) 775-0081 or by email: [email protected] Rev 06_19
