AUTOMATIC BANK DRAFT APPLICATION FORM BANK

AUTOMATIC BANK DRAFT APPLICATION FORM
I hereby authorize Magic Valley Electric Cooperative, Inc. to draft my bank account for the amount due
on my monthly electric bill. I authorize my financial institution to debit the amount monthly from my
checking account.
This authorization is to remain in effect until revoked by MVEC member.
Member Name: ____________________________________________________________________________
Account Number: ___________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State & Zip Code: _______________________________________________________________________
Home Phone: __________________ Cell Phone: ___________________ Work Phone: _________________
E-MAIL: __________________________________________________________________________________
BANK INFORMATION
Name as shown on bank statement: ___________________________________________________________
Name and branch of financial institution: _______________________________________________________
Bank Routing Number: ______________________________________________________________________
Checking Account Number: __________________________________________________________________
_______________________________________________________
DEPOSITOR SIGNATURE
__________________________
DATE
A VOIDED CHECK MUST ACCOMPANY THIS FORM
PLEASE ATTACH VOIDED CHECK HERE
OFFICE USE ONLY:
DATE ENTERED: _______________ BILLING BOOK ____ _ CYCLE: ___ _
EASTERN / WESTERN
ENTERED BY: _______________________