Native Maine ACH Form

Debit Authorization Form
I hereby authorize Native Maine Operations, d/b/a Native Maine Produce & Specialty Foods to initiate a debit entry to my checking/savings account at the Financial Institution indicated below, and initiate adjustments, if necessary, for any transactions debited in error. This authority will remain in effect until Native Maine Produce & Specialty Foods is notified by me in writing to cancel it in such time as to afford Native Maine Produce & Specialty Foods and the Financial Institution a reasonable opportunity to act on it.
Name of Financial Institution*
Financial Institution Location*
City, State
Financial Institution Routing/Transit Number*
(Look between symbols "/: /:" on your check.)
Checking Account Number
and/or
Savings Account Number
and/or
Please attach a copy of a canceled check or deposit slip.

NOTE: If presenting a deposit slip, please verify that the Financial Institution’s Routing/Transit Number is identical. If not, please provide a canceled check and not a deposit slip.
Cancelof
Name and Title*
Company Name*
Phone Number*
Please enter a valid phone number.
Email Address*
Date*

MonthDayYear
Date
Authorized Signature*

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Contact Native Maine’s Credit Manager at 207-856-1100 x110 with questions.
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Debit Authorization Form