Name ______________________________
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Username __________________________
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I (we) hereby authorize ___________________________________,
hereinafter called NetOne Communications, Inc., to initiate debit entries
to my (our) Checking Account / Savings Account (circle one)
indicated below at the depository financial institution named below, and
to debit the same to such account. I (we) acknowledge that the
origination of ACH transactions to my (our) account must comply with the
provisions of U.S. law.
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Depository Name ___________________
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Branch ____________________________
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City ______________________________
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State __________
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Zip ____________
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Routing Number ____________________
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Account Number ____________________
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This authorization is to remain in full force and effect
until NetOne Communications, Inc. has received written notification from
me (or either of us) of its termination in such time and in such manner as
to afford NetOne Communications, Inc. and Depository a reasonable
opportunity to act on it.
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| Name(s) ___________________________ |
Username __________________________ |
(Please Print)
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Date_______________________________
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Signature__________________________
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