ACH form – BostonEats

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BUSINESS INFORMATIONS

Date*

Company Name*

Tax ID No*

Company Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone*

Business Email*

Number of Employees*

Number of Locations*

BANK INFORMATIONS FOR ACH TRANSFER- ONLINE ORDERS & MARKETING ONLY.

This is a secure site, the informations obtain here merely to activate your account.

We need to learn more about you and your business before we/you can process your payments. The information you provide will only be for the use of ACH transactions withdraw/deposit and only visible to the account owner and administrator.

Contact Name*

Position*

Business Owner more than 50%

President/ Partner 50% or more

Partner 50% or more

Cell Phone No*

Your Email*

Date of Birth*

Social Security No ( 9 digits )*

Front Side of Your License*

Back Side of Your License*

Bank Name*

Account Type*

Business Checking

Business Saving

Bank Routing Number*

Bank Account Number*

Void Check*

CREDIT CAR INFORMATION

Credit Card Type*

Master Card

Visa

Discover

Amex

Card Holder Name*

Card Number*

Card Expiration Date*

Card CVC Number

Card Holder Billing Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

I authorize Cieqa Inc./ BostonDelish to charge my credit card or bank account for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

This is a 24 months contract and Credit Card authorization. You may cancel this authorization with registered mail notification 60 days prior of automatic renewal. This authorization will remain in effect until cancelled.

Signature Date*

Signature*

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