MICR____________________________________________________________________________ 1530 Antioch Pike - Antioch, Tn 37013 (615) 277-7139 - FAX (615) 324-3323 WWW.MICR-DATA.COM APPLICATION FOR FLEXI-CHEK(TM) PREAUTHORIZED CHECK SERVICE Legal Name of Business _________________________________________________________ Doing Business As ______________________________________________________________ (Payee Name For Preauthorized Checks) Street Address _________________________________________________________________ City ___________________ State __________________ Zip ____________________ Contact ________________________________ Title _________________________________ Phone ____________________ Fax ______________________ E-mail ___________________ Type of Ownership? [] Corporation How Long in Current Business?________ [] Partnership [] Sole Proprietorship Referred By? [] Internet [] Other ______________________________________ Describe Product or Services ___________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ================================================================================ | | | AUTHORIZATION AGREEMENTS. | | | | Client shall obtain valid, completed and signed authorization | | agreements from all client's individuals or companies for whom MICR will | | produce FLEXI-CHEK(TM) preauthorized payment checks. | | | | DISPUTES WITH CLIENT'S INDIVIDUALS OR COMPANIES. INDEMNIFICATION TO MICR. | | | | All disputes between client and client's individudals or companies | | relating to any preauthorized check transaction shall be settled between | | client and such individual and company. Client agrees to indemnify and hold | | MICR harmless from claim, liability, loss or expenditure relating to such | | transaction and from client's breach of any of its obligations under this | | agreement. | | | | Signed ____________________________ Title ________________________________ | | | | Date _____________________________ | | | ================================================================================ ================================================================================ | NEW CLIENTS | | | When you are approved as a client we will mail a welcome kit with helpful | | materials, including a user manual for our internet ordering system. | | | | Additionally, you will be assigned a client id, user name and password for| | internet ordering. Customers can use the online security system to create and| | maintain users and permission levels for their employees. | | | | ================================================================================ |=========================== FOR MICR USE ONLY ================================| | Date client added to: | | [] Master file __________ By ___________________________ | | [] PAC file __________ By ___________________________ | | [] ISP file __________ By ___________________________ | |==============================================================================| PAYMENT AGREEMENT MICR will collect monies due for orders placed each month by debiting your bank account with a preauthorized check (PAC). A statement for orders filled during the month will be mailed to you at the beginning of the following month. The PAC to debit your account will be deposited on the 7th business day of the month. The initial setup fee will also be collected with a PAC. Please complete the authorization below and fax back the entire application along with a copy of a check from the account to be debited to (615) 333-7814. ================================================================================ | Authorization To Honor Checks Drawn By and Payable To: | | MICR DATA SERVICES, INC. | | | | To The Bank Designated: You are hereby requested and authorized to honor and | | to charge to the account described, checks drawn on such account which are | | payable to the above named Payee. It is agreed that your rights with respect | | to each such checks shall be the same as if it bore a signature | | authorization for such account. It is further agreed that if any such check | | is not honored, whether with or without cause, you shall be under no | | liability whatsoever. This authorization shall continue in force until | | revocation in writing is received by you. | | | | Name of Bank _______________________________________________________________ | | | | Street Address _____________________________________________________________ | | | | City, State, ZIP Code ______________________________________________________ | | | | Bank Account In Name Of ____________________________________________________ | | | | Account No. ________________________________________________________________ | | | | Signature of Owner ___________________________________ Date ________________ | | | | Signature of Co-Owner ________________________________ Date ________________ | | (If any) | | Copyright (C) MICR 2002 | ================================================================================ * * * * * * END FORM * * * * * *