Bank Account Change Request Form

Wireless Monthly Service

Customer Name*

Primary Street Address*

Secondary Street Address

City*

State*

Zip*

Phone Number*

Fax Number

Email*

PREVIOUS ACCOUNT INFORMATION (IF EXISTING CUSTOMER)

Bank Name

Routing Number

Account Number

NEW/UPDATED BANK INFORMATION

MULTIPLE USE ACH AUTHORIZATION RELEASE

The customer identified above, by his/her signature below, hereby authorizes Wireless ATM Store and its financial institution, to initiate and/or transmit multiple automatic clearing house (ACH) debit entries to the customer’s account identified herein below. The parties agree and understand that this ACH authorization is for multiple debit entries (a credit entry shall only be authorized for a reversal related to this transaction). Customer acknowledges that the purpose of this ACH release is for the payment to Wireless ATM Store for services from Wireless ATM Store to the customer and that this constitutes a valid business relationship between the two parties. The customer agrees to indemnify and hold Wireless ATM Store and/or customer’s financial institution harmless from any and all claims associated with compliance with the aforementioned multiple use ACH authority. The customer agrees to provide a voided check to properly validate customer’s account and routing numbers.

ANY UNIT DEEMED TO EXCESSIVELY EXCEED DATA USAGE LIMITS WILL BE SUSPENDED IMMEDIATELY, AND MAY BE SUBJECT TO A REACTIVATION FEE.

Bank Name*

Routing Number*

Account Number*

I agree that submitting this form constitutes my pen-and-paper signature*