EZ-Pay

Restaurant Name

Customer Number

(If unknown, enter 000000)

Full Name of Authorized Signer on Account

Payment Method

Default ACH account

Name on the Bank Account

Billing Address

Email Address for Receipts/Notifications

Phone Number Associated With Bank Account

Bank Name

Routing Number

Account Number

Re-Enter Account Number

Account Type

Checking

Savings

Apply Credit Memos Automatically

Yes

Payment Preference

"Hands Free" - We initiate the payment automatically on the invoice due date. You receive a confirmation email

"Full Control" - You initiate the payment from our secure online portal

Additional Notes

*By typing your name in the box below, you agree that you have read and agree to the terms and conditions located at the end of this form*

Signature