Company Name:

Phone Number:

Name On check:

Bank Name:

I authorize A-1 Internet Service Provider to use automatic check drafting as the method of payment for my services through their company. I realize that no signature is needed on these checks and that if I dispute a charge through my bank this will constitute a breach of contract, resulting in immediate deactivation of my reseller ID.

A-1 Internet Service Provider Customer. (initial one)

____ - please use Check Drafting for my monthly invoice.

____ - please use Check Drafting only on request.

____ - please use Check Drafting on a one-time basis: Amount = $______________
 

I have included a blank voided check along with the signed copy
of this automatic check authorization form.
 

Signature _______________________________________ Date ____________________

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INCLUDE PHOTO COPY OF CHECK BELOW THIS LINE

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