The merchant named below hereby authorizes and requests WEX Inc. and/or WEX Bank (collectively referred to hereafter as “WEX”) to make payment of amounts owing to MERCHANT by initializing credit entries to MERCHANT’S demand deposit account at the bank named below (“MERCHANT’S BANK”), and authorizes and requests MERCHANT’S BANK to accept any credit entries initiated by WEX to such account without responsibility for the correctness thereof. In the event of any overpayment or payment in error, MERCHANT hereby authorizes WEX to initiate a debit entry to the same account for each overpayment or payment in error. Merchant Name/Legal Name Merchant Mailing Address City State Zip WEX Settle Entity ID WEX Site IDs [This number is required and is located on the topleft [Note: Changes to your bank information will affect all sites attached to corner of your settlement report.] your Settle Entity ID.] □ Check this box to authorize the banking change to all of the sites. [Note: If box is left unchecked, we may require additional forms and documentation before making the changes to your setup.] List individual sites here if box is not checked: MERCHANT INFORMATION (If you need to make a change regarding only one of your sites due to an ownership change or reorganization of your business, please call 8886608941 for additional instructions. Do not submit this form if you only want to change information related to one or a few of your sites.) It is understood that for purposes of this agreement, the term “MERCHANT’S BANK” shall mean and include the bank identified below by MERCHANT and any successor bank identified to WEX in a Notice of Change provided to WEX by any Automated Clearing House Association processing credit or debit transactions under this Agreement. MERCHANT may also provide written notice to WEX that it has terminated its relationship with MERCHANT’S BANK. In order for payments to continue, MERCHANT shall provide WEX with the information below for its new MERCHANT BANK. Any such notification to WEX shall be effective only with respect to entries credited to the MERCHANT’S account by MERCHANT’S BANK after receipt of such notification and a reasonable time to act on it. Bank Name and Address ABA Routing Number Account Name Account Number REQUIRED: INCLUDE A COPY OF A VOIDED CHECK SHOWING BUSINESS NAME AND ADDRESS. DEPOSIT SLIPS AND STARTER CHECKS ARE NOT VALID. OR, PROVIDE A LETTER FROM YOUR BANK ON BANK LETTERHEAD CONFIRMING YOUR ROUTING AND ACCOUNT NUMBERS. SUCH A LETTER MUST BE SIGNED BY A BANK AUTHORITY. WEX BANKING AUTHORIZATION BANK ACCOUNT INFORMATION Signature Printed Name X Title Date Phone Email AUTHORIZED SIGNATURE WEXSF 20141219 WEX.NEWBCFl 6/13 WEX MERCHANT BANKING AUTHORIZATION AND CHANGE FORM PLEASE FAX ALL DOCUMENTS TO 2072531379