Influence Direct, Inc.

Mail Payment Authorization - ACH

ACH Direct Debit: I/We (“Client”) hereby authorize Influence Direct, Inc. to debit my/our checking account for the amount indicated below. I (we) also acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. By filling out the form below, you acknowledge approval for ACH Direct Debit to your account for our services. Charges will appear from Influence Direct, In. on your statement.


Name on Account:

Account Number:

Routing Number:

Bank Name:


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Billing City: Billing State: Billing Zip:

I/We authorize Influence Direct, Inc. to debit our account in the total amount of: $.

This is a one time debit only and covers Invoice(s) #


By signing below, you (Client) agree to remit full payment for your Project to Influence Direct, Inc. You also agree that the proofs are correct as ordered. Influence Direct, Inc. assumes no liability for the results of your mailing campaign. A completed order for a Project consists of an authorized invoice, signed proofs, data and payment. Influence Direct, Inc. cannot guarantee specific drop dates of your mail campaign, when/if any inbound calls begin and delivery time frames of the United States Postal Service. You also agree that the Project services for which payment is provided herewith are subject to all terms and conditions contained in the Contract for Services between Influence Direct, Inc. and Client.

Customer Name:

Print Authorized Name:


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Influence Direct, Inc.
Signature Certificate
Document name: Mail Payment Authorization - ACH
Unique Document ID: 7f3a87ae6a0cb0aa59378fd7b48afbccad59fae8
Timestamp Audit
2016-04-25 11:21:30 CDTMail Payment Authorization - ACH Uploaded by Jeremy Crosslin - IP