ACH Update | Card Concepts Inc.

This form has been sent in regards to a change in existing service provided by Card Concepts Inc. This agreement will update and replace your existing agreement with Card Concepts Inc.

CCI Account Number*

CCI Product Family*

Owner Name*

First Last

Owner Email*

Owner Phone*

Legal Name of Business*

Doing Business As (DBA) Name*

Social Security (SSN) or Tax ID (EIN)*

DBA Address*

Street Address Address Line 2 City State Zip Code

Account Type*

Name on Account*

ABA Routing Number*

9-digits

Bank Account Number*

Bank Name*

Bank Address*

Street Address Address Line 2 City State Zip Code

I hereby authorize Card Concepts Inc. (hereafter "CCI") and the credit card gateway service (CreditCardGatewayFees.GatewayService) to initiate debit entries for the sums detailed above and initiate (if necessary) credit entries and adjustments for any debit entries in error to the account indicated in bank information named above, to debit and/or credit the same to such account.

This authority is to remain in full force and effect until CCI has received written notification from customer of said authority's termination and in such manner as to afford CCI a reasonable opportunity to act.

To agree to all terms above and contained herein, please enter your full name below and sign with your mouse/finger.

Please type out your full name.*

Signature*

ACH Update Form