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10.8.2007
Eastern Pennsylvania Business Journal
Stroudsburg firm advocates check service for merchants.
3.1.2007
ChekNews
Our Merchant Member Newsletter
ChekXcept Card
Enrollment Application
* Required Information. Please enter all information of n/a were needed.
Your Information
First Name:
*
Middle Initial:
Last Name:
*
Primary
Address line 1:
*
Primary
Address line 2:
*
Primary City:
*
Primary State:
*
Primary Zip:
*
Home Phone:
*
Second Home Phone:
*
Cell Phone:
*
Email:
*
Number of Family Members:
*
Driver License # and State:
*
Last 4 digits of Social Security #:
*
Secondary Address
(if applicable)
Secondary
Address line 1:
*
Secondary
Address line 2:
*
Secondary City:
*
Secondary State:
*
Secondary Zip:
*
Work Information
Employer:
*
Work Phone:
*
Work Address 1:
*
Work Address 2:
*
Work City:
*
Work State:
*
Work Zip:
*
Previous Address
(previous address in the past 5 years if different than above)
Previous
Address line 1:
*
Previous
Address line 2:
*
Previous City:
*
Previous State:
*
Previous Zip:
*
Authorization for Electronic Recurring Debit
I understand the ChekXcept Card is FREE for the first 30 days. Thereafter, I authorize ChekXcept, or its agent, American DebtWorks, Inc. to deduct a recurring membership charge of $0.42 per month directly from my checking account during my first twelve month introductory membership period. If I choose to remain a member, I authorize ChekXcept to deduct a recurring monthly membership fee, as stated in my renewal application, for the term of such renewal. I understand I must keep my membership information current and if I change my banking information or contact information, I must update my membership profile on line at www.chekxcept.com and there will be NO charge for updating my profile. However there will be a charge of $10.00 for replacing a lost ChekXcept Card which I also authorize ChekXcept™ to deduct from my account electronically.
Name of Bank:
*
Routing Number:
*
Bank Account Number:
*
Authorization:
*
(type your name)
Member Agreement & Authorization
PRIVACY POLICY
- The applicant acknowledges and agrees that personal membership information may not be released, sold or assigned to any company or organization that is not a member of our network or their collection agent, Information may be released to participating members for (1) purposes of providing the enrollee with discounts and other shopping incentives when using a check to purchase goods or services and (2) in the legal collection of a debt, in the event the enrollee writes a check that is returned unpaid.
ALL INFORMATION WILL BE VERIFIED. INVALID INFORMATION WILL REVOKE CARD PRIVILEGES
This card can only be used by the applicant and cannot be assigned or used by any other member of the household. All other family members, including your spouse, must apply separately.
ChekXcept Authorization
The undersigned authorizes the participating merchant or his agent, American DebtWorks, Inc. dba ChekXcept to debit my checking account electronically for the face amount of any returned check plus a processing fee as allowable by state law, in the event a check I write at any location within the ChekXcept network is returned unpaid. I further acknowledge that this authorization is expressly given and implied every time and any time I write a check at any participating merchant location within the ChekXcept network where the ChekXcept logo is displayed. I also acknowledge and understand that I may revoke this authorization by calling 1-888-282-2802. If I revoke this authorization, this ChekXcept Card will be cancelled and my right to use a check to pay for goods and services at member locations may be revoked.
CHECK WRITER INFORMATION MUST BE UPDATED ANNUALLY ONLINE AT WWW.CHEKXCEPT.COM. FAILURE TO UPDATE INFORMATION ANNUALLY INVALIDATES CARD!
Promo Code:
(if any)
Signature:
*
(type your name)
Date:
*
To better protect your information, please enter the security code shown in the box here.
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