I authorize
Energy Efficient Solutions, LLC
to initiate a
one-time electronic debit (ACH/eCheck)
from the bank account identified on this authorization form
for the amount shown above, for payment of the invoice or
order identified above.
I certify that I am an authorized signer on the bank account
identified above and that the information provided is accurate.
This authorization applies only to the single payment described
on this form and does not authorize recurring or future debits.
I understand that the debit may be initiated on or after the
date I sign this authorization. I may revoke this authorization
by contacting Energy Efficient Solutions, LLC
before the debit has been initiated. If the payment is returned
or rejected by my financial institution, any applicable fees
or other amounts remain subject to the terms governing the
underlying invoice or order.
Return instructions:
After printing and physically signing this form, return a clear photo or scan of the signed authorization using the email or text instructions provided by your Energy Efficient Solutions representative.
This page does not submit the information you enter.
The information remains in your browser solely so you can
print the completed authorization form.
