Lunchbox Setup and Subscription fees (use this one)

ACH AUTHORIZATION

Schedule your payment to be automatically deducted from your bank account. Just complete and sign this form to get started!

Auto-Payments Will Make Your Life Easier:
• It’s convenient (saving you time and postage)
• Your payment is always on time (even if you’re out of town), eliminating late charges.

Here’s How Recurring Payments Work:
You authorize the scheduled charge to your checking/savings account. You will be charged the monthly below subscription amount billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or license fee amount changes, in which case you will receive notice from us at least 5 days prior to the payment being collected. Any Dispatch delivery payments may be billed weekly and will change each week based on usage.

Your Name*

Prefix (optional)

First Name

Initial (optional)

Last Name

Email Address*

Your Restaurant Group *

e.g Bareburger, McDonalds, Clean Juice

Your Location Name*

As it appears in your point of sale system

Business Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is the billing address the same as the business address?*

Yes No

Your Phone Number*

Business EIN

Will you be the primary billing contact for this account?*

Yes No

Billing Contact Name*

First Name

Last Name

Billing Email*

Billing Phone*

Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

INFORMATION REQUESTED

Bank Account #*

Bank Routing #*

Name on Account*

Bank Name*

Bank City/State*

Account Type*

Personal Business

Checking Savings

CONSENT

Authorization*

I authorize (1) Lunchbox Technologies Inc to charge my bank account indicated above for the monthly subscription and setup fee amounts agreed upon in the client service agreement executed by the restaurant group, and (3) Nash Technologies Inc (Lunchbox's delivery coordination partner) to charge the same account, weekly, for delivery provider fees incurred, which may vary based on delivery volume. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Lunchbox Technologies Inc in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Lunchbox Technologies Inc, or Nash Technologies Inc, may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Signature*

[clear]

Use your mouse or finger to draw your signature above