Its Your ATM so do more with it.

Location Name

Contact

Address

City

State

Zip

Phone #

(hereinafter referred to as Customer) authorizes YourATM.com Inc., or its designated assignee, referred to as YourATM.com, to initiate ACH transfer entries and to debit and/or credit the account identified herein for all Processing Services. This authorization shall remain in effect unless and until YourATM.com has received written notification from Customer that this authorization has been terminated in such time and manner to allow YourATM.com to act. YourATM.com shall have the right to credit and debit Account for the settlement of Terminal transactions and transaction adjustments on behalf of Customer. This terminal is sponsored by Meta Bank.

Customer agrees that it shall, itself or through a third party, keep its Terminals supplied with sufficient cash, receipt paper, and any and all materials necessary to maintain operation of such Terminals. All shortages and adjustments must be reported to YourATM.com within 7 days or Customer assumes full liability. Customer further agrees to comply with all electronic-fund-transfer network rules, regulations and requirements. Customer has the authority to authorize YourATM.com to process their ATM transactions and enter into this agreement. Customer shall hold YourATM.com harmless and indemnify, including attorney fees, in the event of a claim.

Print Name: v

Signature: X Date: v

FUNDS SETTLEMENT INFORMATION

Bank Name/Branch

Bank Officer

Account Name

Phone

Account Type ™ Checking ™ Savings

Address

Accum Type ™ Lumped ™ Separate

City

State

Zip

Account Owner________________________please print

Routing #

Account #

FIN Tax:

SS Number:

ATTACH PRE-PRINTED VOIDED CHECK

This authorization will not be activated without receipt of a copy of a PRE-PRINTED check, or a letter from the above financial institution verifying the routing and account numbers and account name.