Travel Authorization Form ACH

MADURO TRAVEL INC./MADURO DIVE ACH DEBIT AUTHORIZATION --- USA CHECKING/SAVINGS ACCOUNTS ONLY - INDIVIDUAL ACH MUST BE A TRAVELER NAMED ON RV

This authorization is only used for all payment(s), deposit and/or final payment, associated with the supplied Maduro invoice RV # specified. After receiving fully completed authorization from Business/Individual Named, your account will be debited. For your security, all information submitted is fully encrypted on our database. All payments are in USDollars. * Indicates required information in order to submit.

Select One:*
Checking AccountSavings Account
(all debit authorization information must match to the selected payment account)

Business/Individual Legal Bank/Depository Account Name*

Business/Individual Name if different from above

DEBIT AUTHORIZATION

I/we authorize Maduro Travel Inc. DBA Maduro Dive, to initiate debit entries to our account indicated below at the depository financial institution named below. I/we understand that this authorization will remain in full force and effect until the RV# below is paid. I/we can notify [email protected] to revoke this authorization only before debit is completed which is 24 hours after submission.

Business/Individual Debit Information*

Financial Institution/Depository Name*

Amount

Account Number*

ACH Routing Number*

Maduro Invoice RV#*

Date Travel Begins*

This authorization is only used for all payment(s) associated with the supplied Maduro invoice RV # specified. After receiving this authorization from the Business/Individual Named, your account will be debited. For your security, all information sent is database encrypted.

Business/Individual Account Holder Debit Authorization*

Full Name*

Date*

Print Your Bank/Depository Signature (Type E-Signature)*

Email address to send you notice that authorization was received*

CHECKING THE BOX TO THE LEFT DENOTES ACCEPTANCE OF OUR Terms and Conditions*

I/WE AUTHORIZE MADURO TRAVEL INC. DBA MADURO DIVE, TO INITIATE DEBIT ENTRIES TO OUR ACCOUNT*

CHECKING THIS BOX ACKNOWLEDGES YOU HAVE BEEN PROVIDED THE LINK FOR TRAVEL TRIP INSURANCE*

CHECKING THIS BOX ACKNOWLEDGES A $25 FEE FOR SUBMITTING AN ACH WITH INCORRECT INFORMATION*

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Travel Authorization Form ACH

MADURO TRAVEL INC./MADURO DIVE ACH DEBIT AUTHORIZATION --- USA CHECKING/SAVINGS ACCOUNTS ONLY - INDIVIDUAL ACH MUST BE A TRAVELER NAMED ON RV

DEBIT AUTHORIZATION

Business/Individual Debit Information*

Business/Individual Account Holder Debit Authorization*

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