eCheck Form

Use this form to submit your E-check information.

CONTACT INFORMATION

Company/Organization *

Your Name *

Email Address *

Phone Number *



Authorization Statement

I authorize ChristianNetcast.com to initiate either an electronic debit or to create and process a demand draft against my bank account according to the terms outlined below. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

Terms of Billing

Account will be debited on/after the 1st of each month for the total amount owed to merchant.

Bank Information

Bank Name *

Bank Account Type *

Bank Routing Number *

Bank Account Number *

This payment authorization is to remain in full force and effect until the customer notifies ChristianNetcast.com of its cancellation by sending written notice in such time and in such manner to allow both ChristianNetcast.com and receiving financial institution a reasonable opportunity to act on it.

Authorized Approval Name *

Electronic Debit Approval *
Yes, I approve

Date *


Comments



By clicking "Send", you confirm and approve that your account will automatically be charged, on or after the 1st of each month, for the balance due on your account.