ONE TIME ACH PAYMENT AUTHORIZATION FORM Website Ach_customer Customer

User Manual: ach_customer

Open the PDF directly: View PDF .
Page Count: 1

Metroline Inc.

2250 Meijer Drive | Troy, MI 48084 | 800-929-8061 | Fax 248-655-1456

Please return Authorization by Fax or Email to:

(248) 655-1456 or orders@metrolineinc.com

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: $ _________________________