Payment Authorization Form

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Please use the form below to set up automatic recurring payments for your monthly IT service.

If you have any questions or need assistance with the form, please email MJ at mj@datalys.it.

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the greater of the amount indicated on your invoice, or the account's outstanding balance 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. Should payment fail to process for any reason you agree to provide an alternate method within 5 calendar days.

Company Name *

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone Number *

Email Address *

What type of account will you use? *Checking / Savings AccountCredit Card

Checking / Savings Account

Bank Account Type *CheckingSavings

Name on Account *

Billing Address *

Bank Name *

Bank City/State *

Account Number *

Routing Number *

Please upload a voided check *

No file chosen

Void a check and upload a scan or picture of it. This is to ensure the accuracy of the account and routing numbers.

Credit Card

Type of Card *VisaMasterCardAmEx

Cardholder First Name *

Cardholder Last Name *

Billing Address *

Card Number *

Expiration Date *

Please select the first day of the month unless your card indicates otherwise.

CVV2 *

Authorization

I hereby authorize Datalys IT to initiate debits to my account indicated above for the purpose of satisfying any outstanding invoices. I authorize the depository financial institution named above to process said entries. I understand that amounts are variable with each billing cycle. I waive my right to receive written notice of varying amounts.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Datalys IT in writing of any changes in my account information or termination of this authorization at least 10 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 Datalys IT 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.

I understand and agree to the above *Yes

Digital Signature *

Date *

Please do not fill in this field.

Payment Authorization Form

Please use the form below to set up automatic recurring payments for your monthly IT service.

Here’s How Recurring Payments Work:

Checking / Savings Account

Credit Card

Payment Authorization Form

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