BACK TO TOP
SECURITY
RESIDENTIAL
COMMERCIAL
INSTALLATION
SYSTEMS
CCTV
ACCESS CONTROL
FIRE ALARM SYSTEMS
HOME AUTOMATION
WIRING & NETWORKING
HOME AUDIO & VIDEO
CENTRALVAC
FEATURED PRODUCTS
SERVICES
HOW-TO VIDEOS
ABOUT US

REQUEST A QUOTE
RECURRING PAYMENTS
SERVICE REQUESTS
EMAIL US

ACH Recurring Payment Authorization Form

Please fill out the electronic form below or print this form, fill out all information, and mail to:
Select One Security
PO Box 4246
Lawrence, KS 66046

This seal verifies that this form is SSL protected. An SSL creates a secure tunnel through which information including usernames, passwords, credit card numbers and more can pass safely.

* = required

I (Your Full Name*) authorize Select One Security LLC to charge my bank account indicated below of each monthly, quarterly or annually for payment of my security monitoring bill on the 1st of the month.

Billing Address*
City*
State*
Zip*
Phone Number*
Email Address*

Account Type*

Name on Account*
Bank Name/Credit Card Type*
Account Number*
Credit Card Expiration Month/Year (i.e. 01/2016 - required if credit card)
CVV2 (Credit Card Security Code - on the back of card - required if credit card)
Bank Routing Number (required if checking or savings account)
Billing address and zip code for credit card (required if credit card)

Electronic Authorization Signature:

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Select One Security LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Select One Security LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.


×
Select One Security and Communications
2152 East 25th Place Lawrence, KS 66046 US
Phone: 785-843-3434 Website: https://selectonesecurity.com/