AUTHORIZATION AGREEMENT
FOR PREAUTHORIZED PAYMENTS
INFOBAHN OUTFITTERS
I (we) hereby authorize INFOBAHN OUTFITTERS, hereinafter called COMPANY, to initiate debit entries to my (our) Checking or Savings account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to such account.
DEPOSITORY NAME
CITY _______________________________ STATE _________ ZIP ___________
TRANSIT/ABA NO. ____________________DDA ACCT NO. _______________
ACCOUNT TYPE (indicate one): CHECKING [ ] or SAVINGS [ ]
This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
NAME(S) ___________________________________
Please
print
___________________________________
Please
print
SIGNATURE _________________________________
DATE _________________________________
SIGNATURE _________________________________
DATE _________________________________
ACCOUNT(S) AT INFOBAHN OUTFITTERS TO BE PAID:
YOUR EMAIL ADDRESS(S): __________________________________________
YOUR ACCOUNT ID(S): (leave blank if unknown): __________________________
Please provide one of your VOIDED checks to attach to this document to ensure proper routing of transaction. Thank you.
Return to:
Infobahn Outfitters, Inc.
PO Box 248
716 E. Jackson St.
Macomb IL 61455-0248