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Contact Information
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Afterhours Phone #
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Accounting
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Factoring Company Name
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Account Rep
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ACH Authorization Form
***this form MUST be accompanied by a Printed Voided Check***
Name
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Phone #
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Email
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Carrier
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Driver
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Address
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City
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State
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Zip Code
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Bank Information
Bank Name
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Account Owner
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Account Name
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Address
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City
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State
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Zip Code
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Routing #
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9 digits number
0 / 9
Account #
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Account number
Name and Last Name
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**authorizes Betancorp Logistics, or its designated assignee to initiate ACH transfer entries and to credit the account identified herein for payments. This authorization shall remain in effect unless and until USA Truck Brokers has received written notification from vendor that this authorization has been terminated in such time and manner to allow Betancorp Logistics to act. Undersigned represents and warrants to Betancorp Logistics that the person executing this Release is an authorized signatory on the Account referenced above and all information regarding the Account and Account Owner is true and correct
Account Owner Signature
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Date
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Print name and title:
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Attach Pre-Printed Voided Check
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Documents
Signed Agreement
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Signed and dated W9
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Copy of MC Authority
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Certificate of Insurance
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with Betancorp Logistics as certificate holder
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