Customer Information

Full Name

Billing Address

Address

Phone

Payment Details (ACH – Checking Account)

Authorized Amount ($)

Account Holder Name

Bank Name

Routing Number

Account Number

Payment Type

Authorization & Agreement

By signing below, I confirm that I am either the account holder or an authorized signer for the bank account listed above. I certify that this account is active, valid, and capable of processing ACH transactions.

I hereby authorize Maison Group LLC to initiate a one-time electronic debit from the account provided. I also authorize Maison Group LLC to credit the same account if necessary to correct any processing error.

This authorization applies to a single transaction only. In the event that the debit is declined or returned, I understand that the transaction may be reprocessed in accordance with applicable laws.

Right to Revoke Authorization

I understand that I may cancel or revoke this authorization by contacting Maison Group LLC via phone or email at least three (3) business days prior.

Signature

Customer Signature (Type Full Name)

Date

I agree to the terms