ACH Single Transaction Authorization

Date:

Stanton Account Number:

Your Email Address:

Bank Information

Last 4 Digits of Bank Account # to Charge:

Your Invoice(s)

PLEASE PROVIDE PAYMENT APPLICATION INFORMATION:

NOTE: An ACH will NOT be processed without complete details.

* Press the + to add an additional invoice and/or order # to this authorization.

ACH TOTAL:

You hereby authorize Stanton Carpet Corporation, including its divisions, affiliates or subsidiaries to initiate an ACH draft to your account at the financial Institution designated by the routing number named in this authorization (the "Financial Institution"), for payment of the full amount due on invoice(s) or orders indicated on this authorization form. You further authorize the Financial Institution to accept these debit entries as valid debit activities under your account. You also agree that you will immediately reimburse Stanton for any dishonored ACH's against the account that you have provided to us in this authorization and agree to pay a Twenty Five($25) dollar fee if this ACH is dishonored for any reason. You agree to hold Stanton harmless from any and all losses or liabilities arising from any transactions or occurrences relating to this ACH authorization.

Authorized By: