Monthly Payment Enrollment
Your monthly managed services will be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card.

You authorize regularly scheduled charges to your checking/savings account or credit/debit card. If you choose bank draft, your bank statement will display Flux Labs.

There will be a 3.5% convenience fee all CC methods. There is no fee for ACH.
Please complete the information below.

I authorize Flux Labs to draft my bank account OR charge my credit/debit card based on the information provided below.
Choose Payment Option*
- Bank Account/ACH Withdrawal
- Credit/Debit
ACH / Bank Information
Account Type
- Checking
- Savings
Name on Account*
Name on Account*
Routing Number*
Account Number*
Bank Name*
Card Type*
- Visa
- MasterCard
- American Express
- Discover
Credit / Debit Information
Cardholder Name*
Card Number*
Expiration Date*
Security Code*
Zip Code*

Agency Name*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Authorized Agent Representative*
Email*
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Flux Labs 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 payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions and these funds may be withdrawn from my account immediately on your billing date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF), I understand that Flux Labs may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

I certify that I am an authorized user of this debit card/credit card/bank account and will not dispute these scheduled transactions with my bank or credit card or debit card company.
Authorized Agency Representative Signature*
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Date
MM slash DD slash YYYY
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IP Address
Comments
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Monthly Payment Enrollment