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: _______________________
© Copyright 2018 AnyForm