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Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Email(Required)

PREVIOUS ACCOUNT INFORMATION (IF EXISTING CUSTOMER)

Old Bank Name

Old Bank Accounting Number

Old Bank Routing Number

NEW/UPDATED BANK INFORMATION MULTIPLE USE ACH AUTHORIZATION RELEASE The customer identified above, by his/her signature below, hereby authorizes Wireless ATM Store and its financial institution, to initiate and/or transmit multiple automatic clearing house (ACH) debit entries to the customer’s account identified herein below. The parties agree and understand that this ACH authorization is for multiple debit entries (a credit entry shall only be authorized for a reversal related to this transaction). Customer acknowledges that the purpose of this ACH release is for the payment to Wireless ATM Store for services from Wireless ATM Store to the customer and that this constitutes a valid business relationship between the two parties. The customer agrees to indemnify and hold Wireless ATM Store and/or customer’s financial institution harmless from any and all claims associated with compliance with the aforementioned multiple use ACH authority. The customer agrees to provide a voided check to properly validate customer’s account and routing numbers. ANY UNIT DEEMED TO EXCESSIVELY EXCEED DATA USAGE LIMITS WILL BE SUSPENDED IMMEDIATELY, AND MAY BE SUBJECT TO A REACTIVATION FEE.

New Bank Name(Required)

New Bank Account Number(Required)

New Bank Routing Number(Required)

Signature consent(Required)

I agree that submitting this form consitutes my pen-and-paper signature

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