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AUTHORIZATION AGREEMENT FOR RECURRINNG DIRECT PAYMENTS (ACH DEBITS)

Customer Name:
I,_____________________, hereby authorize Hercules Pharmaceuticals, Inc., (“Hercules”) to debit the bank
account indicated below for my payment obligations to Hercules. For each transaction, Hercules shall
issue an invoice, which contains the amount owed and the payment due date. I authorize Hercules to
debit my account on the due date of each invoice received, in the amount indicated on the invoices.

Account Type: Checking Savings

Bank Name:
Bank Address:
Account Name:
Account Number:
Routing Number:
Amount of Debit:

This authorization shall remain in full force and effect until Hercules has received written
notification from the below signed party of its termination of such authorization.
Notification of termination of authorization shall be given in a reasonable time and
manner.
Account Holder Name:
(please print)

Account Signatory:
Date:

27 Seaview Boulevard • Port Washington • New York 11050

ACH Recurring Payment Form
PHONE: 1 (212) 390-8577 • FAX: 1 (212) 390-8578
Version: 1
Document update: 2020_0325
www.herculesrx.com