Justin Long LLC Recurring ACH Payment Authorization FormName *Date Agreement I hereby authorize Justin Long LLC, 1407 NW 202nd St, Newberry FL 32669 to make a recurring debit to my checking or savings account for $100 on or after the 1st day of the month on a monthly basis. I also authorize a one-time debit of the full amount of the website construction fee, if applicable.I agreeName of Bank *Name on Account *Account type *CheckingSavingsRouting Number *Account Number * By signing this form electronically, you give Justin Long LLC permission to debit your account for the amount indicated on or after the indicated date. This is permission for the recurring amount and frequency listed above, and does not provide authorization for any additional unrelated debits or credits to your account. This authorization is to remain in full force and effect until Justin Long, LLC has received an acknowledged notification or written notice to the address listed above. You may cancel payment with a phone call or email notification, as well.Type full name as valid electronic signature * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
