NAC_Direct Payment Form

Direct Credit Agreement Form

I hereby authorize National Automotive Charging Systems Inc. to electronically credit my (our) account at the financial institution listed below.
Further, I agree not to hold National Automotive Charging Systems Inc. responsible for any delay, loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in crediting funds to my account. PLEASE SELECT ONLY ONE BELOW:*

CheckingSavings
At the depository financial institution named below (Depository) I (we) agree that ACH transactions I (we) authorize comply with all applicable laws.
Account Information
Depository Name*
Depository Address (Bank Address)*
Routing Number*
Account Number*
Account Title*

PersonalBusiness
Account Title*
Contact Phone Number*
Print Name*
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Title (for Business)*
Dealership Name*
Should be Empty:

Account Information