consumer_authorization_form.pdf
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The Town of Centreville 101 Lawyers Row Centreville, MD 21617 410-758-1180 fax 410-758-4741 www.townofcentreville.org
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
CUSTOMER NAME (S) ______________________________________________________
I (we) hereby authorize Town Council of Centreville, hereinafter called COMPANY, to initiate debit entries to my (our) Checking account indicated below and the financial institution named below, hereinafter called BANK, to debit the same to such account.
BANK NAME ____________________________________________________
BRANCH ______________________________________________
CITY _____________________________ STATE ___________ ZIP ___________________
TRANSIT/ABA/ROUTING NO. _______________________________________
ACCOUNT NO. _________________________________________
A voided check or deposit slip is required to accompany this form.
This authority is to remain in full force and effect until COMPANY and BANK has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
CUSTOMER NAME (S) ___________________________________________________
(PLEASE PRINT)
DATE __________________________________
SIGNED ________________________________ SIGNED ____________________________