Debit Authorization Form

Debit Authorization

I hereby authorize Greenfield Banking Company hereinafter called GBC to initiate debit entries to my (our) account indicated below and the financial institution below, hereinafter called FINANCIAL INSTITUTION to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
Financial Institution Name
Branch Address
Bank Informa-tion

Routing NumberAccount Number
Type of Acount

CheckingSavings
Name

First NameLast Name
This authority is to remain in full force and effect until GBC has received written notification from me (or either of us) of its termination in such time and manner as to afford GBC and FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Signature
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Amount to be Deducted
Yes, I want to be a GCSF Visionary

for the next 3 yearsfor the next 5 years
Check One

Monthly on the 1st of each monthMonthly on the 15th of each monthAnnually on this date _______________
Should be Empty: