AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT
Company Name: Amherst Trucking Inc. to initiate debit entries to my (our) Account at the Financial Institution named below and to debit the same to such Account. I (we) acknowledge that the origination of ACH transactions to my (our) Account must comply with the provisions of U.S. law.
Account Information:
Financial Institution Name_______________________________________________________________
City__________________________________________State________Zip____________________
Financial Institution Routing Number______________________________________________________
Account Number___________________________________ Account Type________________________
(checking or savings)
Name(s)_____________________________________ ______________________________________
(Please Print) (Please Print)
Service Address______________________________ Amherst Trucking Acct. #__________
**** ATTACH COPY OF VOIDED CHECK ****
Check one Payment option:
Quarterly _______ (6/15, 9/15, 12/15 and 3/15) Bi-Annually______ (6/15 and 12/15)
Authorized Signature(s):
Signature_______________________________________________Date__________________________
Signature_______________________________________________Date__________________________
This authorization is to remain in full force and effect until Amherst Trucking Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as Amherst Trucking Inc. and the Financial Institution has had a reasonable opportunity to act on it.
Mail completed form to:
Amherst Trucking Inc.
Attn: Liz Pitts
P.O. Box 39
No. Hatfield, MA 01066