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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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If you are interested in learning more about the Toshiba and/or Lexmark Office Equipment that Howard D. Happy Co., sells, or if you are interested in requesting a quote for Toshiba and/or Lexmark Equipment from Howard D. Happy Co., please fill in the information below and click ‘submit’.

If you would prefer to contact us by phone you can reach us at 800-858-0492.

Thank you!

Customer Name

Contact Name

Phone

Email Address

Please provide a brief description of what type of equipment needs you may have

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If you are interested in learning more about the Office Furniture that Howard D. Happy Co., sells, or if you are interested in requesting a quote for Office Furniture from Howard D. Happy Co., please fill in the information below and click ‘submit’.

If you would prefer to contact us by phone you can reach us at 800-858-0492.

Thank you!

Customer Name

Contact Name

Phone

Email Address

Please provide a brief description of what type of furniture needs you may have

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