I (We) hereby authorize Premium Merchant Funding 26 LLC (Company) to initiate entries to my (our) checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error.
Name of Financial Institution *
Routing Number *
Account Number *
We offer 2 payment options:
-- select one --One-Time PaymentFixed Recurring Payments
Authorization for a single, specified payment.
Please make this charge on: *
for the amount of $ *
Authorization for recurring payments on a daily/weekly/monthly basis, specifying the amount of each debit, until the total balance has been satisfied.
Please start the charges on: *
Select frequency: *dailyweeklymonthly
Business Name * Business ZIP Code * Your Signature *
Today's Date *
If you should need to notify us of your intent to cancel and/or revoke this authorization you must contact us 3 days prior to the questioned debit being initiated. Please call 516-696-7863 or email [email protected], Monday - Friday from 9:00am to 5:00pm.