ACH Application - POET Bioproducts

Customer:

Contact Name:

Phone:

Address:

City:

State:

Zip:

"Customer" does hereby authorize Poet Bioproducts to initiate debit and/or credit entries to Customer's Bank account indicated below for payment/refund of any debt incurred for purchase of product, and does further authorize the depository institution named below to debit/credit such entries to the Customer's account:

Bank & Branch:

Bank Contact:

Phone:

Address:

City:

State:

Zip:

Routing and Transit Number:

Account #:

Neither party shall be liable to the other for any failures or errors beyond its reasonable control including without limitation, mechanical, electronic, or communications failures or errors. Neither party shall be liable to the other for any special incidental, exemplary or consequential damages arising from or as a result of any delay, omission, error or failure in the electronic transfer of funds.

This authority shall remain in effect until terminated upon 30 days written notice by either Customer or Poet Bioproducts. Notice of the termination shall in no way affect debit/credit entries initiated prior to actual receipt of notice.

All credit and other terms and requirements between Customer and Poet Bioproducts remain in effect.

OPTIONAL: Scan and attach a voided check.

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Signature

Title

Friday, April 26, 2024

By entering your name and title in this section, you indicate that all of the information provided in the above form is accurate, that you are a legal representative of the applicant, and that you agree to all terms as stated. Submission of your name here shall be considered your electronic signature for all fields on this page and supplied attachments.

SUBMIT

POET Bioproducts - Funds Transfer Authorization Agreement