Electronic Funds Transfer Authorization Form printable pdf download

Electronic Funds Transfer Authorization Form

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

1) I, the undersigned, certify that I am a signer on the account listed below with the authority to grant this authorization.

2) I, the undersigned, certify that MERRITT VETERINARY SUPPLIES or any agents of MERRITT VETERINARY SUPPLIES is

authorized to debit the account referenced below via draft (ACH) or other Electronic Funds Transfers (EFT).

3) I, the undersigned, certify that the bank referenced below is hereby requested, authorized and directed to honor and

treat as authorized, checks, drafts or moneys drawn in my name in accordance with this authorization.

4) I, the undersigned, certify that in the event any such draft or EFT is returned unpaid, I agree to have the account ref-

erenced below debited electronically or otherwise drafted for an item fee of $30.00, plus any applicable taxes.

5) I, the undersigned, [ ] (if checked) authorize MERRITT VETERINARY SUPPLIES to initiate recurring EFT drafts on the

account to pay outstanding balances and obligations as they become due.

6) I, the undersigned, certify that this authorization shall remain in effect and the authority herein given to MERRITT

VETERINARY SUPPLIES shall remain irrevocable until MERRITT VETERINARY SUPPLIES receives written notice of revo-

cation of such authority. Revocation shall not affect any action taken prior to receipt of such notice.

Business Name: _____________________________________________ Account: ________________

Street Address: ______________________________________________________________________

City: ______________________________________

State: __________

Zip Code: _____________

Phone: ____________________________________

Fax: ___________________________________

Bank Name: ________________________________________________________________________

ABA/Transit Routing #: ____________________________

Account: __________________________

Authorized Signature: _________________________________________________________________

Name & Title: ____________________________________________________

Date: ____________

FAX FORM AND/OR CHECK TO:

803.695.6909

E-MAIL FORM AND/OR CHECK TO:

REV. 02.26.13

Electronic Funds Transfer Authorization Form