Collins DISH Retailer Application - Page 5

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER ( EFT ) Retailer Payment Options ( check one ):
____ Payment by Electronic Funds Transfer ( EFT ) - By checking this box you are agreeing to receive payments by EFT . You must attach a pre-printed company check from your business account to this form in order to receive payments by EFT .
Retailer Name : ___________________________________________________________________________________________________________________________
Address ( city , state , zip ): ___________________________________________________________________________________________________________________
Retailer TCG I . D . No .: ______________________________________________ Federal Tax I . D . No . ( EIN ): ________________________________________________
Phone : __________________________ E-mail : _______________________________________________________________________________________________
Name of Financial Institution : ________________________________________________________________________________________________________________
Address ( city , state , zip ): ___________________________________________________________________________________________________________________
Bank Routing No . ( 9 digits ): _____________________________________ Acct . No .: ________________________________________ Checking ___ Savings ___ I authorize Collins Distribution to initiate credit entries to my bank account at the bank indicated on the attached check (“ Bank ”). I understand and agree that if an erroneous credit is made to my account that Collins Distribution and Bank are authorized to stop payment , reverse the entry or make any adjustments necessary to my account to correct the erroneous entry .
I understand and agree that I may terminate this agreement at any time by providing seven ( 7 ) business days ’ prior written notice to Collins Distribution . Notification to Collins Distribution shall be effective upon receipt at : Collins Distribution , Attn : Mandy David , 1139 S . Baldwin Ave ., Marion , IN 46953 .
I acknowledge and agree that checks with company names that do not match the company listed on this form will not be set up for EFT .
Account Holder ’ s Authorized Signature : _____________________________________________________________________________ Date : _____________________
Account Holder ’ s Printed Name : _____________________________________________________________________________________________________________
PLEASE SIGN THIS FORM , ATTACH A VOIDED CHECK , AND EMAIL TO : accounting @ thecollinsgroup . us
Allow two weeks for your application to be processed .
For questions call Collins Distribution at ( 800 ) 825-1100 5