AUTHORIZATION FOR AUTOMATIC DEPOSIT ALACK REFRIGERATION COMPANY, INC.
Employee Information: Employee Name:
Social Security #:
Address:
City, State, Zip:
Home Phone:
I hereby authorize Alack Refrigeration Company, Inc. to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account indicated below and the Depository named below to credit and/or debit the same said account.
This authority is to remain in full force and effect until Alack Refrigeration Company, Inc. has received written notification from me of its termination and in such manner as to afford Alack Refrigeration Company, Inc. and Depository a reasonable opportunity to act on it.
Signature:
Date:
Employee Bank information: (Please attach a voided check or savings account ticket so that we can insure the correct account information is properly recorded.) Bank #1 Bank Name:
Bank Address:
City, State, Zip:
Routing/Transit No.:
Account Number:
This is a:
Checking Account
Amount for this account:
$
or
Savings Account
%
Bank #2 Bank Name:
Bank Address:
City, State, Zip:
Routing/Transit No.:
Account Number:
This is a:
Amount for this account:
Checking Account
$
or
Savings Account
%