Online Payment – One Time E-check

Contact Information
Name:*
First Last
Company Name:
Phone Number*
Email Address:*
Enter Email Confirm Email
Billing Address:*
Street Address Address Line 2 City State ZIP Code
Invoice Information
Invoice Number:*
Invoice Due Date:*
MM slash DD slash YYYY
Invoice Amount:*
Please enter a number greater than or equal to 1.
Banking Information
Bank ABA Number:*
Bank Account Number:*
Bank Account Type:*
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I hereby agree to the Solutions Squad Inc Business Agreement attached and/or available at https://solutionssquad.com/businessagreement and authorize Solutions Squad Inc to initiate either an electronic debit or to create and process a demand draft against my bank account on or after 05/20/2022 for the amount indicated in the "Invoice Amount" field on this form. I understand that my information will be saved in a secure database and indemnify Solutions Squad Inc from any damages resulting from the utilization of this form. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law and confirm that my account information is as indicated above. My IP address (35.170.82.159) and/or electronic signature will herein serve as my affirmation of the above.
Signature*
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Contact Information