Draft / Signature Authorization
I agree that the electronic media record of my transactions held by America TAB, Ltd. (service@americatab.com) shall be used as the final determination to resolve any dispute I may have. I understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in the America TAB Legal Notices and agree to abide by all the rules, terms, conditions, and agreements therein and as amended from time to time.
(Please complete one form for each separate checking/credit card account)
| Account Number: | ____________________ (note: enter your AmericaTab account #) |
| Name: | ______________________________________________________ |
| Address Line #1: | ______________________________________________________ |
| Address Line #2: | ______________________________________________________ |
| City: | _________________________________ State: ___________ |
| Zip Code: | __________ |
| Home Phone: | ______________________ Fax: _______________________ |
| Work Phone: | ____________________ |
| E-Mail Address: | ______________________________________________________ |
| Date of Birth: | _____ / _____ / _______ |
Credit / Debit Card:
| Type of Card: | _____________ (MasterCard/Visa) |
| Card Number: | ________________________________________________ |
| Expiration Date: | _____ / _______ |
| Name as Shown on Card: | ________________________________________________ |
*Please accept this as authorization for America TAB, Ltd. to draft the above listed credit card and continue such authorization until I notify America TAB, Ltd. and the bank listed in writing.
Additionally, I authorize America TAB, Ltd. to issue payment in accordance with electronic requests for withdraw of funds from my account, and understand no withdraw of funds requests will be processed without a signature on file.
| Signature: __________________________________ | Date: ________________ |
PLEASE RETURN THIS FORM AS SOON AS POSSIBLE.
| Via Fax: | Via U.S. Mail: |
| (859) 223-9141 | America TAB P.O. Box 8510 Lexington, KY 40503 |