Registration Form

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Electronic Credit and Payment Authorization


Subject to (i) the terms set forth in the Merchant Application Form dated as of 5/23/2018, submitted by (“Merchant”) (ii) The Preferred Prepaid’s Merchant Services Terms of Use, (iii) the Operating Rules of the National Automated Clearing House Association, and (iv) applicable federal regulations governing Automated Clearing House (“ACH”) transactions, I (we) do hereby authorize The Preferred Prepaid, and any partner or subsidiary or affiliates of The Preferred Prepaid, namely ePay or Emida or TCetra, Inc (collectively referred to as “The Preferred Prepaid” for the purposes of this ACH Authorization) to initiate debit and credit entries to the account specified below for obligations owing from time to time resulting from the transactions described in the Merchant Services Terms of Use. I certify under penalty of perjury that am a duly authorized as a check signer on the account identified below and am authorized to provide all relevant consents and representations contained in this ACH Authorization, as evidenced by my signature below or by pressing the agreement button. In the event that THE PREFERRED PREPAID incurs any charges due to failure of an ACH debit to properly process to Merchant’s account specified above (after several attempts by The Preferred Prepaid), or in the event that such account does not have sufficient funds to permit the ACH debit to go through, I (we) hereby grant THE PREFERRED PREPAID the authority to debit the account for all such charges and expenses incurred together with a $25 administrative fee per failed ACH. This authorization is to remain in full force and effect until THE PREFERRED PREPAID has received written notification from me or another duly authorized representative of Merchant of it’s the termination hereof in such time and in such manner as to afford THE PREFERRED PREPAID and its partners, a reasonable opportunity to act on it.

All information gathered in this form will be kept strictly confidential

The data remains confidential; The information you provide will be kept in a secure environment. The privacy of the information you provide will be safeguarded and only disclosed if required by law.

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