AUTHORIZATION FOR DIRECT PAYMENT

I authorize ____________________________________________ and financial institution named below to initiate
----------------------------------(COMPANY NAME)
entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution 3 days before my account is charged.
________________________________________________________________________________________________
(NAME OF FINANCIAL INSTITUTION)---------------------------------------------------------------------------------------------------(BRANCH)
________________________________________________________________________________________________
(CITY)------------------------------------------------------------------------(STATE)------------------------------------------------------(ZIP CODE)
________________________________________________________________________________________________
(SIGNATURE)-------------------------------------------------------------------------------------------------------------------------------(DATE)
________________________________________________________________________________________________

(NAME - PLEASE PRINT)
________________________________________________________________________________________________
(ADDRESS - PLEASE PRINT)
Account No.____________________________________ Checking _______ Or Savings ________

Financial Institution Routing Number __________________________________________________
----------------------------------------------------(between these symbols l:-----------l: on the bottom left of your check)


STAPLE VOIDED CHECK HERE

RETAIN FOR YOUR RECORDS

On ______________________ I authorized
---------------------(DATE)
_______________________________________________________________________________________________
(COMPANY NAME & DEPT.)
_______________________________________________________________________________________________
(ADDRESS)

PHONE __________________________________

to initiate electronic entries to my checking/savings account and have agreed to the terms listed on the authorization. I may revoke my authorization with the company at any time by writing to the address above.

Initial payment amount: $_________ Regular payment date: __________

(if payment amount changes we will notify you at least 10 days before the regularly scheduled payment date.)