Electronic Payment Authorization – Palm Beach Financial Exchange, Inc.

Payment Authorization Form

This Electronic Payment Authorization Form is to acknowledge and establish Palm Beach Financial Exchange, Inc. (PBFE) electronically debit Merchant’s Checking, Savings, Credit Card or Debit Card for the purpose of recurring transaction payment processing for Merchant’s goods and services received from PBFE.

Step 1 of 2

* ALL SENSITIVE INFORMATION IS ENCRYPTED FOR YOUR SECURITY AND NOT SHARED WITH ANY OTHER ENTITY.
BUSINESS INFORMATION
Corporation Name:*
Enter the name of your corporation.
Business Name (DBA):
Enter the name of the business.
Business Phone:*
Enter the business telephone number.
Business Website:
Enter the business website address.
Contact Name:*
Enter the billing contact name.
First Last
Contact Email Address:*
Enter the billing contact email address.
Enter Email Confirm Email
Business Address:*
Enter your business address.

Street Address Address Line 2 City State ZIP Code
Goods/Services:*
Select the nature of the business.
EIN – Tax ID*
Enter the Employer – Tax Id number.
Corporate Phone:*
Enter the corporate phone.
Contact Email:*
Corporate contact email.
Corporate Address:*
Corporate Address same as Business Address

Street Address Address Line 2 City State ZIP Code
Corporate Contact:*
Enter the corporate contact name.
First Last
Contact Title:*
Enter contact title.

PBFE AUTHORIZATION
Debit Date :*
MERCHANT acknowledges PBFE will debit MERCHANT’s payment account of the FIRST OF EVERY MONTH. I understand payment amounts may fluctuate based upon the amount of fees and services provided by PBFE to MERCHANT.
- Payments are Debitted on the 1st of each month.
Payment Method :*
MERCHANT authorizes PBFE to debit for goods and services by the chosen payment method:
- Checking / Savings Account
- Credit Card / Debit Card
Bank Name :*
Please enter the name of your financial institution.
Bank Routing Number :*
Enter the Routing number of your financial Institution.
Bank Account Number :*
Please enter the your account number at your financial Institution.
Credit / Debit Card Number :*
Please enter your Credit / Debit card number.
Credit / Debit Card Expiration Date :*
Please enter your Credit / Debit card number.
3 Digit Security Code:*
Please enter your Credit / Debit card 3 digit security code.
Consent to Bank Account Activity:*
This ELECTRONIC FUNDS TRANSFER AGREEMENT by and between the above named business (“MERCHANT”) and PALM BEACH FINANCIAL EXCHANGE, INC. (“PBFE”), becomes effective upon the MERCHANT’s signature being affixed hereto.

MERCHANT hereby authorizes PBFE in accordance with this Processing Agreement to initiate debit/credit entries to the MERCHANT’s checking accounts, savings accounts, and/or credit cards for the purposes of rendering payment for MERCHANT’s goods and/or services.

PBFE is the processing agent for MERCHANT’s payments to PBFE. This Authority is to remain in full force and effect until PBFE has received written notification from MERCHANT of its’ termination in such a manner as to afford PBFE reasonable opportunity to act on said termination and all obligations of Merchant to PBFE that have arisen under this AGREEMENT have been paid in full including but not limited to, those obligations of outstanding returns for non collectable debits.

PBFE reserves the right to terminate this Agreement at any time. For Value Received, and in consideration for the undertakings contained in the ELECTRONIC FUNDS TRANSFER AGREEMENT by and between MERCHANT and PBFE, the undersigned jointly, and severally if more than one, unconditionally guarantees to PBFE, its successors and assigns, the full and prompt payment when due of all of the obligations of every kind and nature of MERCHANT arising directly or indirectly out of this Agreement or any document or agreement executed and delivered by MERCHANT in accordance with the terms of this Agreement. The undersigned further agrees to pay PBFE all expenses (including attorneys’ fees and court costs) paid or incurred by PBFE including such obligations, and enforcing this Guaranty. This Agreement and Guaranty shall be governed in accordance with the laws of the State of Florida.

TERMS AND CONDITIONS
Terms and Conditions governing this agreement between the Merchant (the Originator) named in this Electronic Funds Transfer Agreement and PBFE and its officers, employees, affiliates, licensees and agents:

WHEREAS: Merchant desires to pay PBFE by Automated Clearing House (ACH) and/other merchant services PBFE’s fees as indicated in this agreement. Transactions are placed through PBFE as third party ACH transactions, paper draft or IRD checks. PBFE will send all transactions through an Origination Depository Financial Institution (ODFI) or merchant services provider in accordance with the terms of this Agreement’, the Operating Rules (Rules) of the National Automated Clearing House Association (NACHA) and the applicable Federal Regulations governing ACH transactions. Entry or Entries shall mean either Credit Entries, a Debit Entries, a paper draft or an IRD as appropriate. Merchant also agrees to comply with all rules at the time each entry is initiated by the Merchant with respect to the most recent NACHA operating rules and that each entry shall in no way breach any Federal, State, or Local statute of regulation pertaining to and for electronic funds transfers, including the Electronic Funds Transfer Act and Regulation E, and all other applicable laws and regulations.
Account Authority
Submitted By:*
Name of the person submitting this banking information.
First Last
Date Submitted:*
Date information submittal.
Month
Day
Year
Name
This field is for validation purposes and should be left unchanged.

Payment Authorization Form

Step 1 of 2

* ALL SENSITIVE INFORMATION IS ENCRYPTED FOR YOUR SECURITY AND NOT SHARED WITH ANY OTHER ENTITY.

BUSINESS INFORMATION

PBFE AUTHORIZATION