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DynaPay™ Sign-Up Form

Customer Name (Organization)
Address
City          State      Zip

Primary Contact
Secondary Contact
Phone       Fax

Service(s) Requested:    EFT Debits     Credit Card Charges

Text to Appear on Donor / Payee's Statement (Limit to 10 Characters Including Spaces, Example: "MSC Gift") 

Desired Statement Dates(s)     10th    25th        Send via:
Fax    Mail    Internet(ID:)

Statement Detail Activity send via:
Fax    Mail    Diskette     PC-to-PCPh#

Format of  Fund Code/Customer ID

Approximate Start Date

Estimated Volume ( Monthly )

Peak Periods

Bank Name  Branch
Address        Phone

I would like help in Developing an Authorization form.