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Secure ACH Payment Authorization
Customer Information
Name
First
Last
Hidden
Date
*
MM slash DD slash YYYY
Email
*
Transfer Information
Frequency
One Time
Reoccurring Monthly
Reoccurring As Needed
Payment Date
*
MM slash DD slash YYYY
Payment Amount
*
Please enter a number greater than or equal to
0
.
First Transfer Date
*
MM slash DD slash YYYY
Day of Month For Future Transfers
*
Please enter a number from
1
to
31
.
First Payment Amount
*
Account Holder Type
*
Consumer
Business
Checking or Savings
*
Checking
Savings
Routing Number
*
Account Number
*
Agreement
This payment authorization is to remain in effect until I notify Torqqe Performance of its cancellation by giving written notice in enough time for Torqqe Performance and receiving financial institution to have a reasonable opportunity to act on it.
I authorize Torqqe Performance to electronically debit my bank account according to the terms outlined here. I acknowledge that electronic debits against my account must comply with United States law.
*
I Agree & Accept
Signature
