NetXS Leasing Inc. Automatic Payment Authorization

Form ACH · v2
17345 Civic Dr. Unit #1326
Brookfield, WI 53045

Automatic Payment Agreement

Please complete all fields below. Your information is transmitted over a secure encrypted connection.

1 Account Reference

Your NetXS customer number, as provided on your invoice or by your account representative.

Customer Number*

Customer number is required.

Date

2 Company Information

Company Name*

Company name is required.

Federal ID (EIN)

DBA Name

Business Address*

Business address is required.

Phone

Cell

Fax

Email*

A valid email is required.

3 ACH Authorization

I hereby authorize NetXS Leasing Inc. or the bearer of this Agreement to initiate automatic withdrawal from the bank account or the credit card for the amount specified below. Additionally, to avoid any late payments, I authorize NetXS Leasing Inc. to automatically charge any amount due on unpaid invoices, signed work orders, signed lease contracts, signed service or other agreements related to our account. This agreement remains in effect for the term specified below from the date of commencement. After expiration, the agreement continues to uphold only for unpaid invoices and signed agreements exceeding the stated term.

Amount (USD)*

Amount is required.

Frequency*

Term*

4 Checking Account

Provide your banking information, or upload a voided check below.

Name of Financial Institution*

Bank name is required.

Branch / State

Account Number*

Account number is required.

Routing Number*

A 9-digit routing number is required.

Account Type

Checking Savings

Voided Check (optional, PDF/JPG/PNG, max 4MB) Click to upload voided check

5 Backup Funding Source (Credit Card)

Optional. Card security code (CVV) is not collected.

Credit Card Number

Expiration (MM/YY)

Card Type

Visa Mastercard Discover American Express

Name on Credit Card

Billing Address

A service fee will be charged for credit cards: 3.5% for Visa, Mastercard & Discover; 4.0% for American Express.

6 Signature

Name*

Signer name is required.

Business Title*

Business title is required.

Authorized Signature*

Sign above with mouse, finger, or stylus

A signature is required.

7 Required Documents

Please attach the following. Accepted formats: PDF, JPG, PNG. Max 4MB each.

Driver's License or State-Issued Photo ID* Click to upload photo ID

Credit Card — Front and Back (optional) Click to upload credit card copy

Encrypted submission · SSL/TLS

✓

Authorization Received

Thank you. Your ACH authorization has been submitted to NetXS Leasing Inc. A confirmation will follow by email.

Reference: —