Payment Authorization

Payment Authorization Form

1. I, the undersigned, certify that I am a signer or authorized user on the account listed below with the authority to grant this authorization.

2. I, the undersigned, certify that Pinnacle Propane or any agent thereof is authorized to debit the account listed via draft (ACH), credit card, or other electronic funds transfers (EFTs).

3. I, the undersigned, certify that the bank or credit provider referenced below is hereby requested, authorized, and directed to honor and treat as authorized, checks, drafts, or monies drawn in my name accordance with this authorization.

4. I, the undersigned, certify that in the event any such draft, EFT, or credit card charge is returned unpaid, I agree to have the account referenced below debited electronically or otherwise drafted for an item fee of $35.00, plus any applicable taxes.

5. I, the undersigned, certify that this authorization shall remain in effect and the authority herein given to Pinnacle Propane shall remain irrevocable until Pinnacle Propane receives written notice of revocation of such authority. Revocation shall not affect any action taken prior to receipt of such notice

*Customer/Company name: *Account #: *Address: *City/State/Zip: *Phone *Email

Apply payment to:

Balance on Account

Invoices

Signature Date

Credit Card Payment

Card Type:

American Express

Discover

Mastercard

Visa

*Billing Zip Code *Name on Card *Payment Date: *Payment amount *Credit Card Number *Expiration Date: *CCV Number

*Frequency

One-Time Payment

Weekly

Monthly

Contract

CC on File (credit card will not be charged until customer contact has been made for authorization)

Draft / Check Payment

Name on Account Payment date Payment amount Bank name: Account #: Routing #

Frequency

One-Time Payment

Weekly

Monthly

Contract

Alliant or Pinnacle Payments

6. I, undersigned (if checked):

I, the undersigned (if checked)

Authorize Pinnacle Propane to initiate recurring EFT drafts or recurring credit card charges on the account to pay outstanding balances and obligations as they become due.

Approximate draft date:

Approximate amount:

Privacy statement

Customer may from time to time provide Pinnacle with information that could be used, alone or in connection with other information, to identify an individual (“personal data”). Commercial customers will obtain any necessary consents from the relevant individuals to allow Pinnacle to process relevant individual personal data. Pinnacle will: (i) protect personal data through at least commercially reasonable administrative, physical, and technological security measures; (ii) act in material compliance with any applicable laws regarding the processing of personal data, including without limitation EU Directive 95/46/EC and the EU General Data Protection Regulation 2016/679 (GDPR); and (iii) comply in any applicable respects with its published Privacy Notice (http://www.pinnaclepropane.com/privacy-notice/)(“Privacy Notice”). If you are an individual Customer, Pinnacle will only process your personal data, and you consent to Pinnacle’s use, disclosure and processing of your personal data, in accordance with this agreement and the Privacy Notice. For more information on your rights regarding your personal data, please refer to the Privacy Notice.

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