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customer ACH form

Customer ACH Form

Customer ACH Form

    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

    p>Bank Address

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

    Customer Authorization:

    Authorized Name/Title

    Authorized Signature

    Date

    HDH Accounts Receivable Use:

    Date Received:

    Date Entered:

    Entered By:

    This authority will remain in effect until THE CUSTOMER notifies Howard D. Happy Co. of Mayfield Inc. in writing to cancel it in such time as to afford the Howard D. Happy Co. of Mayfield Inc. and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.

     
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