AUTHORIZATION FOR AUTOMATIC DEPOSIT Staple Voided Check ...
AUTHORIZATION FOR AUTOMATIC DEPOSIT I authorize Western Consolidated Cooperative to initiate entries to my checking account listed below. This authority will remain in effect until I notify you in writing to cancel it, allowing sufficient time the financial institution a reasonable opportunity to act on it.
Name of Financial Institution To Credit Bank Name:
________________________________________
Location:
________________________________________
Transit Routing #:
________________________________________
Checking Account #:
________________________________________
Authorized By: (Signature)
________________________________________
Date:
________________________________________
Print or Type Name:
________________________________________
Company Name: (If Applicable) ________________________________________ Address:
________________________________________
Phone Number:
________________________________________
Staple Voided Check Here
PLEASE ALLOW 2-3 DAYS FOR DIRECT DEPOSIT TO HIT BANK ACCOUNT 520 County Road 9 • Holloway, MN 56249 • (320) 394-2171 • 1-800-368-3310
Name of Financial Institution To Credit Bank Name:
________________________________________
Location:
________________________________________
Transit Routing #:
________________________________________
Checking Account #:
________________________________________
Authorized By: (Signature)
________________________________________
Date:
________________________________________
Print or Type Name:
________________________________________
Company Name: (If Applicable) ________________________________________ Address:
________________________________________
Phone Number:
________________________________________
Staple Voided Check Here
PLEASE ALLOW 2-3 DAYS FOR DIRECT DEPOSIT TO HIT BANK ACCOUNT 520 County Road 9 • Holloway, MN 56249 • (320) 394-2171 • 1-800-368-3310
