islandhosting.com electronic funds transfer authorization form

islandhosting.com
Electronic Funds Transfer Authorization Form

islandhosting.com
1412 Quadra St.
Victoria, BC
V8W 2L1 Canada
[email protected]

Terms & Conditions I (we) authorize the payee to debit my (our) account as indicated on the attached "void" cheque under the terms and conditions agreed to by me (us) with the payee until such time as written notice to the contrary is given

I (we) acknowledge that delivery of my (our) authorization to the payee constitutes delivery by me (us) to the branch of the financial institution at which I (we) maintain an account and that such financial institution is not required to verify that the payment(s) are drawn in accordance with this authorization. Termination of this authorization does/may not terminate the contract for goods and services exchanged

I (we) will notify the Payee in writing of any changes in the account information or termination of this authorization 30 days prior to the next due date of the pre-authorized debit.

I (we) agree to pay a fee of $20.00 for each transaction that is refused by my (our) financial institution for insufficient funds (NSF).

Items charged under any of the following conditions will be reimbursed subject to written notification by me (us) to the branch of account within 90 days.

I (we) never provided authorization to the payee.
The pre-authorized debit was not drawn in accordance with my (our) authorization.
My (our) authorization was revoked.
The debit was posted to the wrong account due to invalid / incorrect account information supplied by the payee.

I (we) warrant that all persons whose signature(s) are requested to sign on this account have signed the agreement.

Print your Islandhosting.com username here (do not include your password):		_________________________________
Print your name(s) here:		_________________________________
Print your address here:		_________________________________
		_________________________________
Phone:		_________________________________

I (we) authorize IslandNet AMT Solutions Group, Inc. to process a debit, in paper, electronic, or other form in a variable amount: "_______X______", with "variable payment $X" being stated on a statement mailed or e-mailed to me (us) 10 days before the debit date.

I (we) acknowledge that I (we) have read and understood all the provisions contained in the terms and conditions of the pre-authorized payment authorization and that I (we) have received a copy.

_________________________________ _______________________

Signature Date

_________________________________ _______________________

Signature Date