Electronic Funds Transfer Form Midland

Electronic Funds Transfer Form
- We will be using a new processor that requires this form to be completely filled in or a VOIDED CHECK must be attached.
- Please update your contact information including phone number and email if applicable.
- Please remember to sign and date this form.
Please complete the form below or complete and mail in this printable form or fill out the form below
Name *

First Name Last Name
Budget Amount *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Financial Institution Name *
Financial Institution Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Financial Institution Name *
Bank ABA/Transit Number (Routing#) *
Account Number *
Account Type *

Checking Savings
Requested Transfer Time *

7th of each month 21st of the month
By signing this form, I authorize Stanford's Propane Gas LLC, to electronically transfer my budget payments from my account listed above. Signature (type name) *
Date

Month Day Year
Date
Please verify that you are human *
Should be Empty: