ONE TIME ACH PAYMENT AUTHORIZATION FORM Website Ach_customer Customer
User Manual: ach_customer
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Metroline Inc. 2250 Meijer Drive | Troy, MI 48084 | 800-929-8061 | Fax 248-655-1456 One-Time ACH Payment Authorization Form __________________________________ (customer name), hereby (1) authorizes Metroline, Inc., to initiate a debit entry to my (our) account indicated below and the depository (bank) named below, to debit same to such account. Depository (Bank) Name_______________________________________________________ City/State/Zip Code: __________________________________________________________ Telephone/Fax Number: _______________________________________________________ Routing / ABA No: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ Account # __________________________________ Company Name: _____________________________________________________________ Telephone Number: _________________________________ Authorized Signature: _______________________________ Date:_________________ Title: ______________________________________________ Please list MetrolineDirect Order #’s and amounts: MetrolineDirect Order #: Amount Paid: __________________________ $ _________________________ __________________________ $ _________________________ __________________________ $ _________________________ Total Amount: $ _________________________ Please return Authorization by Fax or Email to: (248) 655-1456 or orders@metrolineinc.com
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