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Electronic Funds Transfer FormPAYMENT METHOD:I choose to make payments by:1. __x__ ELECTRONIC FUNDS TRANSFER (EFT) PREFERRED. On or about the 10th of the month for _________________________.Check one: x Checking SavingsPlease complete the below information AND attach copy of a voided check.accountholder name (business or individual)aba routing numberfinancial institution name at which account is heldaccount numberI authorize ______________ to perform a monthly Electronic Funds Transfer (EFT) from my checking/savings account for __________________ services and products. accountholder signaturedateOR 2. _____ CREDIT CARD Processed on or about the _________ of each month.Please complete the below information. cardholder name (business or individual)credit card account numbercard typeexpiration date (MM/YY) MC/Visa Amex Discover Diner’scardholder billing addresscity st zipI authorize _______________ to charge my credit card for __________ services and products. Should my card expire or be declined, I will promptly provide ______________ with new credit card information. Check all that apply:A. _____ Recurring payments of ________. I may revoke this authorization with 30 days’ advance written notice to Business Matters B. ______ One-time payment of $___________cardholder signaturedate____________________________will safeguard the above confidential information and use it only for the above noted purpose; it will not be released to any unauthorized parties. ................
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