Authorization Agreement for Direct Deposit or Payments (ACH)

Company that Higher Resolutions is billing or paying

Company Name *

I (we) hereby authorize Higher Resolutions hereinafter called COMPANY, to initiate entries to my (our) account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Financial Institution Name *

Branch Office

City *

State Abbreviation *

Postal Code *

FI Routing Number *

Bank Account Number *

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it

Name *

Name of person authorized to give authorization

Date *

Today's Date

Signature *

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Email to get confirmation of submission *