ACH / EFT Authorization

I authorize Unishippers to perform scheduled or periodic electronic funds transfer debits from my account identified below for payments due or when applicable. Furthermore, if any such electronics debit (s) should be returned NSF, I authorize Unishippers to collect such debit (s) by electronic debit and subsequently collect a returned debit item fee of $50.00 per transaction by electronic debit from my account identified below. For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the financial institution account identified below. I understand and authorize all of the above as evidenced by my signature below. Please attach a voided check from the account to be debited. *

Yes

Bank Name

Bank Address

Branch

Bank Account Number

Bank Routing Number

Please attach a voided check here

Deduction Frequency

Weekly

Monthly

Bi-Weekly (Every 14 Days)

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