Customer Information:

Customer Name

Customer Account

Address

City

State

Zip

Accounting/ACH Contact Name

Phone

Fax

Email Address for Remittance Advice (**Required**)

Above named Customer hereby authorizes the Howard D. Happy Co. of Mayfield Inc. to originate Automated Clearing House electronic funds transfer (EFT/ACH) payment entries, as indicated below, for payment of goods and/or services.

Banking Information:

Name on Bank Account

Bank Routing Number*

Bank Account

Bank Name

Bank Address

*If you change banks or accounts, please provide at least thirty (30) days written notice. *

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