Document 6526059

Company:
To:
From:
Fax:
Date:
Re: New Billing Authorization
Pages:
BUSINESS NAME:
CUSTOMER #:
ORDER #:
If you opt for the Checking Account payment plan please be sure to fax a VOIDED CHECK back with your
authorization form to my attention. In order to make this change effective in a timely manner please fax back as soon
as possible. For your convenience you may fax this form back to
770-850-2326
If you have any questions or comments please feel free to give us a call at 800-742-3578 Option 2.
Please recycle this fax cover sheet and fax back to me with your
information. To avoid delays please fax this form back as soon as possible.
EXTRA
NOTES:
Napa TRACS
770-956-2626 Office
800-742-3578 Option 2 ext. 2626
770-850-2326 Fax
3100 Windy Hill RD SE
Atlanta, GA 30339
1/29/2013 CSG Payment Change FormC:\Users\Randy\Documents\11AA-Change of Billing Form v3.1.6
Please fax back to NAPA TRACS Please call if you have any questions 800-742-3578 Option 2, Ext. 2626 or Ext. 2687
NAPA Commercial System Group Billing Authorization Form
Please Print
Customer #:
Business Name:
Contact:
Address:
Phone:
City, State, Zip:
Autocare Member #:
PRODUCT
LINK
LINK/MOD
NET
NET/MOD
MOD with PLE
PLE Stand Alone
MOD Estimator
Medium Duty.NET
Tractor-Trailer.NET
Tractor-Trailer.MDY
Back Office
Repair Connect
Smart Call
Total
Terms: TRACS Sales Representatives cannot cancel this contract for you. All rentals have a non-cancelable term of 24 months. This authority is to remain in effect until
NAPA TRACS receives a 30-day written notification in house.
Checking Account Payment Authorization
I hereby authorize Genuine Parts Company (GPC), or its agent, to use my bank account (“the
account”) described on this document to pay for the product(s) ordered as listed on this document. I
understand that each month GPC will automatically deduct this amount from the account. I
understand that it is my responsibility to ensure that sufficient funds are in the account to cover the
rental program. Any charge rejected because of insufficient funds (NSF) will result in a $25 service
charge that will be billed to me along with the rental fees that are rejected. I understand that I am
responsible for the payment of such charges. I also understand that no monthly billing or statements
will be sent. Failure to pay will result in the suspension of use of the product and discontinuation of
product support.
Credit Card Payment Authorization
I hereby authorize Genuine Parts Company (GPC), or its agent, to use my credit card described on
this document to pay for the monthly fee for the product(s) ordered as listed on this document. I
understand that each month GPC will automatically bill this amount against this credit card. It is my
responsibility to notify GPC of any billing changes that may affect this transaction. Any charge
rejected will result in a $25 service charge that will be billed to me along with the rental fees that are
rejected. I understand that I am responsible for the payment of such charges. I understand that no
monthly statements will be sent. Failure to pay will result in the suspension of use of the product and
discontinuation of product support.
Note: If you would like a receipt emailed to you after each transaction please check below and
PRINT a valid email address. This option is only available for Credit or Debit Card payments.
PRINT EMAIL HERE:
Direct Debit Requirements
Voided Check
Check for First Payment
Please Print Clearly
*Important Note: Please do not include the three digit code on the back of your card
referred to as the CVV , CSC, or CVC.
Please Print Clearly
Bank Name
Card Holder
Bank Address
Expiration Date
CC Billing Address (address where credit card statement is mailed
City, State, ZIP
Third Party Billing - If third party billing please include contact name an information
Address
Responsible Billing
Party Name
City, State, ZIP
Phone
Phone
Account Relation
Billing Contact
Print name:
Date:
Office Use Only
Authorized Signature:
1/29/2013 CSG Payment Change FormC:\Users\Randy\Documents\11AA-Change of Billing Form v3.1.6
Please fax back to NAPA TRACS Please call if you have any questions 800-742-3578 Option 2, Ext. 2626 or Ext. 2687
NAPA Commercial System Group Billing Authorization Form
Bank Information
Please include Voided Check
Checking Account
Number
Routing Number
Voided Check
Here
Credit Card Information
Credit Card Number
Office Use only
P & CVV D
Performed By:_____________________
1/29/2013 CSG Payment Change FormC:\Users\Randy\Documents\11AA-Change of Billing Form v3.1.6
Please fax back to NAPA TRACS Please call if you have any questions 800-742-3578 Option 2, Ext. 2626 or Ext. 2687