Bluecube Lifeline ACH Authorization

ACH Authorization

For Commercial Bank Accounts
SIM ONE PAY
950 Milwaukee Ave.
Suite 216
Glenview, IL 60025
888-742-7244
support@simonepay.com
Bluecube Solution, Inc. is authorized to debit my bank account via ACH transfer in payment for products and services purchased.
** Please note that all transactions will appear as “BLUECUBE SOLUTION” on your bank statement

Business Information
Business Name: *
Federal Tax ID Number
State Tax ID Number
Business Address: *
City: *
State:
Zip Code:

Bank Information
Name of Bank *
Bank Contact Name
Bank Contact Telephone
Bank Contact Fax
Account Number *
9-Digit Routing Number *


Authorized Signatory
Name:
Address: *
City: *
State:
Zip Code:
Date:
Please sign below with your mouse or using touch-screen display. *

Voided Check to upload: