CREDIT - PAYMENTAUTHORIZATION FORM Credit Auth Customer InformationCompany Name(Required)Physical Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #Email Account InformationThis Bank Account is enabled for: ACH Draft/EFT Name on Account(Required)For Sales Order/InvoicePayment AmountPlease enter a number greater than or equal to 0.Bank NameBank Routing #Bank Account #Bank Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Indicate type of account Business Personal This Credit Card Account has the following logo Mastercard Visa American Express * Please note there is a 3% fee that will be included in the processing of your credit card. This rate is subject to change at any time. *Name on Account(Required)Sales Order/Invoice #3% Processing Fee ($)Please enter a number greater than or equal to 0.Payment Amount ($)Please enter a number greater than or equal to 0.Card #Expires OnCVV CodeIndicate type of account Business Personal Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorization Agreement I authorize The Platinum Packaging Group Inc. to initiate electronic transactions such as payments, refunds, and/or reversals to the bank or credit card account indicated above, provided each transaction is initiated according to the terms of this Agreement. I certify that I am an authorized representative of the Company indicated above and that I have the authority to enter into this Agreement on the Company’s behalf. Company understands that this authorization will remain in effect until it is canceled in writing, and agrees to notify The Platinum Packaging Group Inc. in writing at least 15 days in advance of any changes in its account information or termination of this authorization. Company understands that because these are electronic transactions, these funds may be withdrawn from its account as soon as the date an individual transaction is authorized, and that it will have limited time to report and dispute errors. In the event of a declined or rejected transaction (due to inaccuracy of Company‐provided information, insufficient funds, or Company and/or Company account provider rejection), Company understands that The Platinum Packaging Group Inc. may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $10.00 charge for each attempt returned either NSF or declined, which will be initiated as a separate transaction from the authorized payment. Company has certified that the above account is enabled and/or active with sufficient funds available, and agrees to reimburse The Platinum Packaging Group Inc. for all penalties and fees incurred. Company acknowledges that the origination of ACH transactions to its account must comply with the provisions of U.S. law Authorized Signature(Required)Date(Required) MM slash DD slash YYYY This field is hidden when viewing the formSite
