Dandy Works ACH Authorization Agreement Customer Information Customer Name Mailing Address City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Phone Number Email Agreement Customer authorizes Dandy Mini Marts, Inc. (herein after referred to as "Dandy") to initiate payment from Customer's checking account indicated below and the Financial institution listed below. Each payment shall be made seven (7) days from the statement close date. Dandy will email notice of the amount and schedule date of payment at least seven (7) days prior to the scheduled transfer date. Bank Name Routing/ABA Number (9 digits) Bank Address Bank City Bank State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Bank ZIP Code Account Number Upload Voided Check This authority is to remain in full force and effect until all amounts due from Customer are paid or until Customer revokes the agreement as herein after provided. No revocation shall be effective until Dandy has received written notification from Customer of the desire to terminate this agreement. The termination of this agreement shall be effective fifteen (15) business days after receipt by Dandy of such notification. By typing your name below, you agree that you are an authorized member of the company and that this will act as your electronic signature. Authorized Signature Title Cards and Permissions Card 1 Vehicle Number Description or Driver's Name Require 4-digit PIN for Purchases? YesNo If Yes, Provide PIN Number Require Odometer Readings for Purchases? YesNo Allow for Use on In-Store Purchases? YesNo ADD ANOTHER CARD Submit Application Vehicle Number [text* vehicle_number[]] Description or Driver's Name [text* description[]] Require 4-digit PIN for Purchases? [select* require_pin[] "Yes" "No"] If Yes, Provide PIN Number [text pin_number[]] Require Odometer Readings for Purchases? [select* require_odometer[] "Yes" "No"] Allow for Use on In-Store Purchases? [select* in_store[] "Yes" "No"]