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First Name:
Last Name:
Online Access Code (Not Necessary for Additional Payment):
Order Number:

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Date:

CREDIT CARD SALE

CARD NUMBER:

TRAN AMOUNT: $

CASH DISC. ADD BACK: $

CARD TYPE:

ORDER NUMBER:

APPROVAL CD:

X

{CARDHOLDER'S SIGNATURE}

I AGREE TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO THE CARD ISSUER AGREEMENT

One Time ACH Payment Authorization Form

Sign and complete this form to authorize to make a one time debit to your checking or savings account.

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This permission is for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

I,

authorize
(full name)

to charge my bank account indicated below for

$

on or after

(amount) (date)
and reference

#

(check #)

Email

Phone #

Account Type: Checking Savings

Name on Account:
Bank Name:
Account Number:
Bank Routing #:
Bank City, State:

X

ACCOUNT HOLDER'S SIGNATURE

I UNDERSTAND THAT BECAUSE THIS IS AN ELECTRONIC TRANSACTION, THESE FUNDS MAY BE WITHDRAWN FROM MY ACCOUNT AS SOON AS THE ABOVE NOTED TRANSACTION DATE. IN THE CASE OF THE PAYMENT BEING REJECTED FOR NON SUFFICIENT FUNDS (NSF) I UNDERSTAND THAT MAY AT ITS DISCRETION ATTEMPT TO PROCESS THE CHARGE AGAIN WITHIN 30 DAYS, AND I AGREE TO AN ADDITIONAL $20.00 CHARGE (OR THE MAXIMUM AUTHORIZED BY STATE LAW) FOR EACH ATTEMPT RETURNED NSF, WHICH WILL BE INITIATED AS A SEPARATE TRANSACTION FROM THE AUTHORIZED PAYMENT. I ACKNOWLEDGE THAT THE ORIGINATION OF ACH TRANSACTIONS TO MY ACCOUNT MUST COMPLY WITH THE PROVISIONS OF U.S. LAW. I WILL NOT DISPUTE BILLING WITH MY BANK SO LONG AS THE TRANSACTION CORRESPONDS TO THE TERMS INDICATED IN THIS AGREEMENT.

I (WE) UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN FULL FORCE AND EFFECT UNTIL I (WE) NOTIFY OR DEALER IN WRITING, BY PHONE OR DEALER LOCATION, THAT I (WE) WISH TO REVOKE THIS AUTHORIZATION. I (WE) UNDERSTAND THAT REQUIRES AT LEAST 5 DAYS.

Order No:

Order Number:
Order Status:
Total Amount Received:
Remaining Balance:
Build On Site Fee is separate from the building cost and is not included in the Balance shown above. Build On Site fee is payable directly to the builder before construction begins.

Card Number:	Expiration Date (MMYY):
CVV2:	Billing Name:
Billing Address:
City:	State/Province:

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Final Review and Signature

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