ACH Fact Sheet and Agreement

You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled. If you do not wish to pay ACH, please let your sales rep know.

Customer Name

Phone

(###)

###

####

Fax

(###)

###

####

Corporate Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address Where You Would Like Notification of ACH to be Sent:

Name of Bank

Routing Number

Account Number

Confirm Account Number

By typing my name in the field below, I hereby authorize Coda Coffee, LLC to initiate withdrawals by electronic funds transfer from my checking account, as identified above, for amounts owed to Coda Coffee, LLC. In addition, the financial institution at which my checking account is held is hereby authorized to debit my checking account for the withdrawals initiated by Coda Coffee, LLC. I acknowledge that the origination of ACH transactions in my account must comply with all applicable laws and the NACHA operating guidelines.

Date

YYYY