EMW Digital

Payment Form

Electronic Funds Transfer Authorization

Kelly Kingston

Chief Operations Officer

For any and all operations, marketing, and general business questions, please feel free to reach out. Kelly will assist in any way she can and is ready to work with you.

Phone: (575) 441-8241
Email: [email protected]

Haley Sumruld

Head of HR/Books/Logistics

For any and all billing-related questions, please feel free to reach out. Haley will assist in any way she can and is ready to work with you.

Phone: (817) 773-0869
Email: [email protected]

Get STARTED.

Please fill out this payment form below and feel free to call or text 575-441-8241 if you have any questions.

Please fill out either Credit/Debit Card Form, ACH Form, or Both.

What form of payment method are you interested in?

Credit/Debit Card

Checking Account (ACH)

Savings Account (ACH)

Your Name(Required)

First Last

Company Name(Required)

Phone(Required)

Email(Required)

BANK ACCOUNT INFORMATION

If you are using a credit card, please scroll below. Do NOT fill out this information.

I (we) hereby authorize Everyman Media Works hereinafter called COMPANY, to initiate credit entries to my (our)

Checking Account (ACH)

Savings Account (ACH)

indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the name to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Bank Branch

Bank Name

Bank City/State/Zip Code

Bank Account #

Bank Routing #

Grantee Name

Grantee Tax ID

Today's Date

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

⬇

CREDIT CARD INFORMATION

If you are using ACH, please scroll above. Do NOT fill out this information.

Name on Card

Credit/Debit Card Number

CVC Code

Expiration (MO/YR)

Address

City

State

Zip Code

Grantee Name

Grantee Tax ID

Today's Date

Consent & Signature Authorization(Required)

I hereby consent to submitting all information to the best of my ability to Everyman Media Works LLC. If I have any changes or need to update any information, I will reach out to Kelly Kingston at [email protected] or Haley Sumruld at [email protected].

Please sign using your mouse or trackpad (computer) or your finger (tablet/phone). The box below is interactive.

You're human, right? Just making sure! 🙂

Comments

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Office Locations

Lubbock, Texas
Houston, Texas

Contact

Lubbock (806) 500-2914
Houston (713) 476-1876

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[email protected]