AUTHORIZATION FOR AUTOMATIC PAYMENT
I authorize PowerWeb Connect to instruct my financial institution to deduct my payments from the account listed
below. This authorization will remain in effect until I have notified Power Web Connect in writing to cancel
it. I can stop payment of any entry by notifying my financial institution three days before my account is charged.
Please deduct my payment on (choose one):
|
|
15th of the month |
|
Last day of month |
Frequency (choose one):
| Your Name |
__________________________________________________________________ |
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| Financial Institution Name |
__________________________________________________________________ |
| |
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| Your Address |
__________________________________________________________________ |
| |
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| Your City, State, Zip |
__________________________________________________________________ |
| |
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| Transit Routing Number |
__________________________________________________________________ |
| |
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| Your Account Number |
__________________________________________________________________ |
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| Signature |
__________________________________________________________________ |
Type of account (choose one):
PLEASE ATTACH VOIDED CHECK
and return to
Power Web Connect
PO Box 738
Beaver Dam, WI 53916