Bank Draft Authorization

Debit Authorization

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Name:*

First NameLast Name
Business Name:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Your Website:
Fill out this field for a one-time draft:
I hereby authorize Griffin Web Design to immediately initiate a single debit to my bank account in the amount of:
Description of one time payment being paid for (hosting, marketing, maintenance, etc...):
Fill out this field for regular monthly drafts:
I authorize Griffin Web Design to initiate monthly debits to my bank account on the fifth of each month or the next business day in the amount of:
Description of subscription being paid for (hosting, marketing, maintenance, etc...):
Financial Institution Name:*
Routing Number:*
Account Number:*
By signing this form, I am stating I am a qualified representative of the company and/or website listed and I agree to the terms above and the regular Terms of Service & Privacy Policy posted at: http://griffinwebdesign.com/pdf/policies.pdf
Your Signature:*

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Debit Authorization