National Email Service ~ Payment Form .pdf
Original filename: National Email Service ~ Payment Form.pdf
Title: Direct Choice Marketing
Author: Luis Schupbach
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Authorization to Create a Check from a FAXED Check
No Personal Checks Accepted
Company Name: ___________________________________________________
City, State & Zip Code
National Email Service, Inc** has permission to charge my bank account as per the
faxed check that accompanies this authorization. The FAXED Check is created
solely for the purpose of facilitating the process and it will never be deposited.
Signature & Title ________________________________________
Print Your Name ________________________________________
WE WILL KEEP YOUR BANKING INFORMATION ON FILE
FOR FUTURE USE ON ORDERS AND PURCHASES.
Returned Check Policy:
I agree to have the amount charged to my account. All information is accurate and I have permissible
access to charge this account. **Checks may be processed under the name: National Email Service or DS
Media. If you are signing up for a month to month agreement, this will be a reoccurring monthly charge.
You must contact us in order to cancel the monthly charge. If you are signing up for the annual plan (12
months prepay), this will be a onetime charge unless requested by your company. I understand No refunds
or charge backs are warranted because I have ordered an exclusive product that is non-returnable. No
refund or exchanges will be offered REGARDLESS OF CIRCUMSTANCES OR SEPARATE ARRANGEMENTS
MADE OUTSIDE OF THESE TERMS AND CONDITIONS. By signing this form you are in agreement with the
above statements. We strive for 100% customer satisfaction; if any issues arise please contact us directly.
PLEASE FAX THE COMPLETED FORM BACK WITH A COPY OF
YOUR CHECK TO BE PROCESSED.
FAX Number: 1 (480) 304-5655
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