EFT AUTHORIZATION

 

 

 

INSTRUCTIONS:  Complete the form below and attach an unsigned and voided

check from this account to assist in verifying data.

 

The undersigned authorizes Apex Oil Company, Inc. hereafter called "Company" to

initiate debit entries to the account indicated below.  In the event an error is made, the

undersigned authorizes the financial institution named below, hereafter called

"Institution", to credit the amount of such error to the account below.

 

This authority is to remain in full force and effect until revoked by the undersigned.  Any 

revocation is effective only after Company has received written notice from the

undersigned to terminate this agreement in such time and manner to afford a reasonable

opportunity to act prior to charging the account.

 

COMPANY NAME______________________________________________________

ADDRESS____________________________________________________ญญญญ__________

CITY, STATE, ZIP_______________________________________________________

PHONE NUMBER___________________CONTACT___________________________

FAX FOR NOTIFICATION________________________________________________

 

BANK NAME___________________________________________________________

BANK ADDRESS________________________________________________________

BANK ACCOUNT NO.___________________ROUTING NO.____________________

BANK PHONE NO._______________BANK CONTACT________________________

 

 

 

AUTHORIZED SIGNATURE_______________________________________________

BUSINESS TITLE______________________DATE_____________________________