Fillable Printable Automatic Bank Draft Application Form - MVEC

Automatic Bank Draft Application Form - MVEC

AUTOMATIC BANK DRAFT APPLICATION FORM

I hereby authorize Magic Valley Electric Cooperative, Inc. to draft my bank account for the amount due

on my monthly electric bill. I authorize my financial institution to debit the amount monthly from my

checking account.

This authorization is to remain in effect until revoked by MVEC member.

Member Name: ____________________________________________________________________________

Account Number: ___________________________________________________________________________

Mailing Address: ____________________________________________________________________________

City, State & Zip Code: _______________________________________________________________________

Home Phone: __________________Cell Phone: ___________________ Work Phone: _________________

E-MAIL: __________________________________________________________________________________

BANK INFORMATION

Name as shown on bank statement: ___________________________________________________________

Name and branch of financial institution: _______________________________________________________

Bank Routing Number: ______________________________________________________________________

Checking Account Number: __________________________________________________________________

_______________________________________________________ __________________________

DEPOSITOR SIGNATURE DATE

A VOIDED CHECK MUST ACCOMPANY THIS FORM

PLEASE ATTACH VOIDED CHECK HERE

OFFICE USE ONLY:

DATE ENTERED: _______________ BILLING BOOK ____ _CYCLE: ___ _ EASTERN / WESTERN ENTERED BY: _______________________