Member-distributor Name: ___________________________________________________
ICS ID#:______________________________
Address: Street:______________________________________________________________________________________________
City:_______________________________________________ State:_______________ Zip
code:____________________
Daytime Phone: (____)___________________________
E-mail: ________________________________________________________
Will this be your form of payment for Monthly AutoShip Program?
Yes
No
(If yes, please attach a completed Monthly AutoShipChange & Enrollment Form)
Bank name: _____________________________________________________ Branch:_____________________________________
Address: Street:_______________________________________________________________________________________________
City:_______________________________________________ State:_______________ Zip
code:_____________________
Daytime phone:(____)_______________
___________________________________________________________________
Account type: Personal Business Bank account number:_______________________________________________________________________
I, the undersigned, give permission to International Chocolate Society, LLC,
to draft my checking account to pay for my product purchases.
Signed:_________________________________
Date:_______________________
If this ACH account is being set up to be used by an ICS Member-distributor other than the person whose name appears on the voided check, the Member-distributor whose name appears on the voided check and a witness of their signing must sign below: I,________________________________________________, am authorizing _____________________________________________
to use my account to pay for their product purchases and I assume all responsibility
for these charges to my account in accordance with this agreement.
Signed:_______________________________ Date:_______________________
Witness signed:_________________________ Date:_______________________
ATTACH VOIDED CHECK HERE (No deposit slips, savings accounts, or starter checks (name must be printed on check).