Company Name ______________________________________
Company ID Number ______________________________
I (we) hereby authorize the Virginia Tech Corporate Research Center, Inc. (VTCRC), to initiate debit entries to my (our) __ Checking __ Savings account indicated below at the depository financial institution names below, hereinafter called DEPOSITORY, and to credit the same to such account.
Depository Name ____________________________________
City _______________________________________________
State ____________________ Zip __________________
Routing Number _____________________________________
Account Number _____________________________________
PLEASE
ATTACH A VOIDED CHECK TO THIS AGREEMENT.
This authorization is to remain in full force and effect until the VTCRC has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the VTCRC and DEPOSITORY a reasonable opportunity to act on it.
The VTCRC is authorized to deduct the following payments from the account noted above.
(Please initial and date next to the payments you would like deducted)
RENT_______________________________________________
DATA______________________________________________
COPIES_____________________________________________
OTHER BILLS_______________________________________
Name(s) ___________________________________________
Date ______________________________________________
Signature __________________________________________
Signature __________________________________________