Latina Boulevard Foods - Direct Payment Application (ACH)

Direct Payment Application
Latina Boulevard Foods, LLC. - Corporate Headquarters

1 Scrivner Drive, Suite 1

Cheektowaga, NY 14227

Phone: 716.656.8400 Fax: 716.656.2100

www.latinaboulevardfoods.com
Direct Payment via ACH is the transfer of funds from a customer account for the purpose of making a payment.
Company Name *
Latina Customer # (Acc. #) *
I (we) authorize Latina Boulevard Foods, LLC. (“COMPANY”), to electronically debit my (our) account per the credit terms set by Latina Boulevard Foods, LLC. (and, if necessary, electronically credit my (our) account to correct erroneous debits) as follows:
Select One: *

Checking Account Savings Account
I (we) agree that ACH transaction authorizations comply with all applicable laws.
Routing # *
Bank Name *
Bank Acc. # *

I (we) understand that this authorization will remain in full effect until I (we) notify Latina Boulevard Foods, LLC, 1 Scrivner Drive, Cheektowaga, NY 14227 that I (we) wish to revoke this authorization. I (we) understand that the COMPANY (Latina) requires at least one day notice in order to cancel this authorization.
Enter the word as it's shown *
Corporate Owner/Officer Signature 1 *

Clear
Name of Signer *

First Name Last Name
Title/Position *
Phone Number (of signer) *

Area Code Phone Number
Email *
example@example.com
Date *

Month Day Year
Date
Corporate Owner/Officer Signature 2 (If Applicable)

Clear
Name of Signer

First Name Last Name
Title/Position
Email
example@example.com
Date

Month Day Year
Date
Should be Empty: