Electronic Funds Transfer Form
I hereby authorize the following company:
Company Name: _______________________________________________________________________________
City: _______________________________________ State: ____________ Zip Code:________________________
To initiate debit entries from my checking account from the financial institution listed below. If any of the information listed below changes I will immediately complete a new authorization agreement within fifteen business days.
Financial Institution Name: _______________________________________________________________________
City: _______________________________________ State: ____________ Zip Code: ________________________
I authorize the above listed company to withdrawal:
___ Reoccurring Flat Amount of $_________________ Or ___ ___________________________________________
___ Monthly ___ Weekly ___ Other ________________________________________________________
# ABA Bank Routing Number AND # Account Number
Please enter the above information from the bottom of you check without the check number. Also, please attach a voided copy of your check. Deposit slips are not accepted. Void the check.
This authority is to remain in effect until the above listed company has received written notification from me with thirty days of its termination in such time to afford the company a reasonable opportunity to act upon the cancellation.
Signature of Officer: ___________________________________________________________ Date: ___/___/_____
Print Name: _____________________________________________________Title: __________________________
This original document shall remain on file and no copies will be accepted. All faxed copies shall be denied.