Authorization Agreement for Direct Payment
_________________________________________________________________
I (we) hereby authorize Avalon Networks, Inc., hereinafter called
COMPANY, to initiate debit entries to my (our) _____Checking
_____Savings account (select one of the previous categories) indicated
below and the financial institution named below, hereinafter called
FINANCIAL INSTITUTION, to debit the same such account. I (we)
acknowledge that the origination of ACH transactions to my (our) account
must comply with the provisions of US law.
Financial Inst. Name_________________________ Branch_____________
Financial Inst. Address__________________________________________
City_____________________ State____________ Zip__________________
Routing Transit #___________________ Account #___________________
This authority is to remain in full force and effect until COMPANY and
FINANCIAL INSTITUTION have received written notification from me
(or either of us) of its termination in such time and in such manner
as to afford COMPANY and FINANCIAL INSTITUTION a reasonable
opportunity to act on it.
Signature(s) _________________________ _________________________
Printed Name(s) ______________________ _________________________
Login/User Name(s) ___________________ _________________________
Today's date ___________________
_________________________________________________________________
Entered in db by __________________________ Date _______________