Credit Application And Agreement Confidential Page 3
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3East Region Customer Financial Services
521 Lake Kathy Drive
Brandon, Fl 33510
PLEASE INCLUDE VOIDED CHECK WITH THIS FORM
************************************************************************************************************
ACH/CHECK ACCEPTANCE FORM
Customer Outlet Number:
Customer Name:
Customer Outlet
_________________________
_______________________________________________
Name on outlet
I hereby authorize, Coca-Cola Refreshments, hereinafter called Company, to initiate debit entries from my Checking
Account indicated below and the depository (Bank, Savings and Loan, Credit Union, etc.) named below, hereinafter
_________________________
called Depository, to debit the same from such account. In the event of an error from my account, I grant the Company
the right to make an adjusting debit or credit entry to my account up to the amount of the error. In the event of the need
to make an adjusting debit entry from my account, the Company will notify me of the adjusting debit entry prior to
making the adjusting entry. In addition, I understand and agree to pay, a $20.00 Service Fee for all items returned for
any reason.
BANK NAME ________________________________
AMOUNT: _____________________
BANK ADDRESS _______________________________________________________________
CITY_____________________________STATE__________________ZIP___________________
BANK TELEPHONE__________________________
BANK #
DDA # (Account #)
____________________________________
___________________________________
This authority may be terminated upon thirty days written notification of your desire to terminated automatic debits to
this Depository. This written notification is to be sent to: Coca-Cola Refreshments. Attn: Credit Department, 521 Lake
Kathy Drive, Brandon, Fl 33510
PRINT NAME ____________________________________________
SIGNATURE: __________________________________________
RECURRING: YES / NO (CIRCLE ONE)
PLEASE SET UP RECURRING ACH TO BE PROCESSED ON THE _____________OF EACH
Date:________________________
MONTH FOR PRIOR MONTHS INVOICES.
INITIAL PAYMENT OF $_________________ TO BE PROCESSED ____ / _____ /__________
FOR INTERNAL USE ONLY
AUTHORIZATION APPROVAL CODE:_____________________________
MANAGEMENT APPROVAL:_____________________________________
CREDIT REP:_________________
AR:_________________
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