LibertyToner.com / e-Check Authorization Agreement

e-Check Authorization Agreement

Please print out this form, fill out completely, and email it to sales@alximaging.com


Checking Account Billing Information:
Name: Phone Number:
Address: City/State:
Suite/Rm/Floor: Postal Code:

Authorized Purchases for:
Company Name: Ship Attn:
Address: Phone Number:
Suite/Rm/Floor: Fax Number:
City/State/Zip: Email:

Checking Account Information:
Check MICR Numbers:
Enter all digits from left to right with no spaces or symbols

For Business Checks, select type of Identification     Fed FIN   SSN  

 

For Personal Checks, select type of  Identification     State DL   SSN  

 

Terms & Conditions of Sale: (Please read and understand before signing)

  • I, the undersigned, agree to pay for all purchases according to the terms & conditions as they appear on the most current web site at ALX Imaging, LLC. I agree to pay all debts incurred within the terms of sale. No terms or conditions of purchase orders different from the terms of ALX Imaging, LLC will become part of the Sales Agreement. I understand and acknowledge that I have checked all information provided to ALX Imaging, LLC and it is correct, and that I have read, understand and agree to all the terms and conditions upon which this and all future purchases are governed. I give ALX Imaging, LLC permission to charge the full amount of all purchases, current & future, to the above mentioned checking account. Purchases included in this agreement will be in behalf of the company and/or individual designated within "Authorized Purchases for:"section in this agreement.
  • If TeleCheck authorizes your transaction, your checking account will be debited electronically through the regular banking system. If the transaction cannot be processed electronically, a paper draft will be created to debit the amount of the transaction from your checking account. Should the draft or EFT be returned unpaid, a return item fee of $20.00 (or the maximum permitted by law), may also be debited from your account, or electronically drafted.

Authorized Signature: Date:

Copyright © 2011/2013  ALX Imaging, LLC ~ 4080 Linne Road ~ Seguin, TX 78155
(210) 651-5000