PLEASE ATTACH VOIDED CHECK HERE

Authorization Agreement for Preauthorized Payments

 
Name (the "Depositor"):

Address:

Username:
 Title: (if a business)

City                                  State   Zip
,
Tax Id or SSI #
  
Bank Name: (the "Depository")
Bank Address:

Type of Account:
Transit ABA No:

Bank Telephone No:
( ) -
Branch No:

City                                  State   Zip
,
Debit Date:
Account No:

Bank Contact (if known)
  

(The "Depositor") authorizes Premier Systems Unlimited, Inc. (the "Company") to initiate the debit or credit entries to the Depositor's account identified above, and authorizes the depository named above (the "Depository") to debit or credit such entries to such account.

You will not receive a paper invoice from Premier Systems Unlimited, Inc. if you choose to participate in the direct debit program.

This authorization shall remain in full force and effective until the Company has received written notification from the Depositor of the Depositor's Termination of this Authorization, and for so long thereafter as is necessary to afford the Company and the Depository a reasonable opportunity to act on such Termination.
  

_______________________________
Print your name
    

_______________________________
Signature
________________
Date