E-Check Recurring Payment Authorization

I authorize Blue Nile Digital Marketing to initiate either an electronic debit or to create and process a demand draft against my bank account according to the terms outlined below.
I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

Applicant's Name
First Name*
Last Name*
Applicant's Email Address*
Applicant's Phone Number
Applicant's Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Name
Routing Number*
Bank Account Number*
Bank Account Type*
Bank Account Type*
By choosing yes below, I authorize Blue Nile Digital Marketing to charge my account.*
E-check will start processing on this date*
E-check will be processed each month on this date until I cancel payment by emailing billing department at billing@blueniledm.com. Subsequent debits will be made at any time for any amounts owed per the pertinent invoice for each month.*
I authorize the following amount to be processed each month.*
Description of the transaction*
Comments For Billing Team
Agreement Signature
This payment authorization is to remain in full force and effect until I, (SIGNATURE BELOW) notify Blue Nile Digital Marketing of its cancellation by sending written notice to billing@blueniledm.com in such time and in such manner to allow both Blue Nile Digital Marketing and the receiving financial institution a reasonable opportunity to act on it.

Type your full name as your signature of agreement
First Name*
Middle Name
Last Name*

E-Check Recurring Payment Authorization

E-Check Recurring Payment Authorization

Company

Our Solutions

Contact Info