Authorization For Electronic Fund Transfer - Metlife Page 2

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AUTHORIZATION FOR ELECTRONIC
FUND TRANSFER
The undersigned hereby authorizes Metropolitan Life Insurance Company (the Company) to initiate
electronic debit entries and any necessary adjustments involving these entries to the account identified
below at: _____________________________________________ (the Bank) and authorize the Bank to
accept such entries and make any necessary adjustments. It is agreed that these entries will be made
under the Rules of the National Automated Clearing House Association.
This authorization will remain in effect until written notice of termination is delivered to the Company in
such time and in such manner so as to afford the Company a reasonable opportunity to act thereon. In
no event shall such termination be effective as to entries processed prior to receipt of such notice.
Account Information:
Bank Name: ______________________________________________________
Bank Address: _____________________________________________________
Street
______________________________________________________
City
State
Zip
Transit Routing #: ____________________________________________________
Account #: ______________________________________________________________
Account Type (Checking/Saving): ______________________________________________
Account Title: ___________________________________________________________
Authorized by:
Signature of Authorizing Party:____________________________________________
Printed Name: ___________________________________________________
Date: ___________________________
North Carolina Medical Society /
Group/Division Name: ___________________________________________________
Practice Name
TS 05621973-
_____________________________________________
Group/Division Number:
Division Number
*************************************************************************************************************************
Please attach a voided check or a photocopy of a canceled check above this line.
Metropolitan Life Insurance Company, New York, NY 10010
Small Market
EFTFORM02 0108

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