Enrollment Form Colonial Transfer Corporation printable pdf download

BI WEEKLY ENROLLMENT FORM

DEALER ID:

PROVIDER ID:

DEALER INFORMATION

ISSUING DEALER

ADDRESS

CITY

STATE

ZIP CODE

PHONE

VEHICLE YEAR

VEHICLE MAKE

VEHICLE MODEL

VEHICLE IDENTIFICATION NO.

CUSTOMER INFORMATION

PURCHASER NAME

(FIRST)

(MI)

(LAST)

EMAIL ADDRESS

SOCIAL SECURITY NUMBER

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP CODE

HOME TELEPHONE

BUSINESS TELEPHONE

PAYMENT INFORMATION

FIRST DEBIT AMOUNT

REGULAR BIWEEKLY DEBIT AMOUNT

MONTHLY PAYMENT AMOUNT TO LENDER

FIRST FULL DEBIT DATE

SECOND BIWEEKLY DEBIT DATE

FIRST PAYMENT DATE TO LENDER

SERVICE CHARGE AMOUNT

DEBIT SERVICE CHARGE

TERM

□

$ 1.95

COLLECTED BY DEALER

DEBIT CUSTOMER ACCOUNT

LIENHOLDER INFORMATION

LIENHOLDER NAME

CITY

STREET ADDRESS

STATE

ZIP CODE

PHONE

MONETARY INFORMATION

CLIENTS BANK

ACCOUNT #

ROUTING #

PHONE #

ACCOUNT TYPE

□

CHECKING

SAVINGS

Debit Authorization:

Customer hereby requests that the Administrator, as soon as possible, complete any and all actions necessary to commence debit entries to Customer’s checking/debit

account as set forth below or on the attached voided check. Customer hereby directs his/her bank to IMMEDIATELY honor all Electronic Fund Transfers (the “ETF”) as directed by the Administrator until

customer revokes this authorization, in writing. Customer also directs his/her bank to charge Customer’s account $25.00 for each ETF which is declined or returned for any reason whatsoever. Customer

directs the Administrator to debit Customer’s financial institution every two weeks, and, in addition, to charge the Customer the sum of $1.95 for each ETF transaction from Customer’s account set forth

below. Additionally, Customer authorizes the Administrator to change any and all relevant Customer information necessary to continue the intent of the Parties to this Biweekly Plan Agreement (“PLAN”) in

order to insure the successful implementation and completion of the PLAN including, but not limited to: bank account information and account numbers, bank routing information, Customer address and

the like. In the event of such changes, Customer acknowledges that it is not necessary to re-execute this document.

Acknowledgement

: Customer acknowledges that he/she has read and understands this entire agreement, including the terms on the reverse side hereof and agrees to all the terms and

conditions contained herein. Customer acknowledges that in the event that Customer’s Debt Authorization fails for any reason whatsoever that Administrator may, in its sole discretion, cancel this

Biweekly Plan Agreement. In such an event, Customer acknowledges that he/she shall be solely responsible for making any payments to Lender thereafter without liability of any sort or nature by

Administrator.

Customer Signature: ______________________________________________________________________________

Date:

FAX FORM TO (518) 899-3028

Colonial Transfer Corp – PO Box 391 - Saratoga Springs - New York – 12866

Phone # - (518) 899-1562

Toll Free 1 (866) 882-3110