Electronic Check Authorization

One Time E-Check Payment Authorization Form

Sign and complete this form to authorize Elan Caterers LLC to make a one time debit to your debit to your accout. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

 

Please complete the information below :

I, (Your Name Below) *
I, (Your Name Below)
And/Or on behalf of
And/Or on behalf of
$
On or After *
On or After
Date & Description of Event
Phone *
Phone
Electronic Check Form
Name of Account *
Name of Account
Address of Account *
Address of Account
Date *
Date
I authorize the above named business to debit my account indicated in this authorization form according to the terms outlined above. This Payment authorization is for the event described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this Credit/Debit Card and that I will not dispute payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this form.