ACH Debit Authorization Form

Required fields are marked *

Company Information
Legal Company Name*
DBA
Street Address*
Street Address City State ZIP Code
Phone*
Fax
Effective Date*
MM slash DD slash YYYY
Bank Information
Bank Name*
Bank Street Address*
Street Address City State ZIP Code
Bank Contact Name*
Bank Phone*
Transit/ABA or Routing #*
Account #*
Authorization
I hereby authorize Benz Oil Company Inc. to initiate debit/credit entries to my account indicated above in the amounts equal to each invoice and I authorize the depository financial institution named above to process said entries. I understand that invoice amounts are variable with each pay period. I waive my right to receive written notice of varying amounts and elect instead to be notified two days prior to each pay date of the exact amount of the invoice for that pay period. I agree that the effective date of each debit will be the same as the pay date for that period, and that if the above-named bank rejects or declines to pay for any reason a debit initiated under this agreement, the full amount of the invoice will be due immediately in certified funds.

This authority is to remain in full force and effect until Benz Oil Company has received written notification from me of its termination in such manner as to afford Benz Oil Company and its own financial institution a reasonable opportunity to act on it.
Authorized Signature*

Completing this field will act as your authorized signature.
Date*
MM slash DD slash YYYY
Name and Title (Must be Account Signer)*

33742

Company Information