Shielded Ventures LLC

Authorization Form

ACH Authorization Form

(U.S. Banks only)

Please complete this authorization form. All information will remain confidential. You authorize Shielded Ventures LLC (3455 Peachtree Rd NE 5th Fl, Atlanta, GA, 30326) for a single or regularly scheduled charge to your credit card or bank account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided, and the charge will appear on your credit card or bank statement in the name of Shielded Ventures LLC. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least (2) days prior to the payment being collected.

Payment Information:

By checking “Yes” and opting to pay by electronic debit against the bank account specified above, I agree and stipulate to all statements:

  1. I am the legal owner, have power of attorney, or have legal authority in relation to the bank account specified above to be used for payment.
  2. Such bank account is open, validly issued, in good standing and able to accept electronic debits.
  3. Shielded Ventures LLC is authorized to electronically debit the bank account shown above, and if necessary, to credit such account to correct any erroneous debits using an ACH debit entry.
  4. This ACH debit authorization will remain in full force and effect for this single debit entry only.
  5. Shielded Ventures LLC may re-debit my account for the payment in the event such is dishonored by my financial institution.

Customer Signature:

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