indiana beverage automatic payment programenrollment form Customer Name (as shown on invoice) * Company Name (as shown on invoice) * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Name * First Name Last Name Name of Financial Institution * Branch * Pay invoice from * Checking Account Savings Account Routing Number * Checking Number * Terms and Conditions * I (we) authorize Indiana Beverage to initiate debit entries to my (our) checking/savings account at the depository financial institution named above and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authority will remain in effect until I notify you in writing my desire to cancel. I understand that in the event a payment is returned to Indiana Beverage as dishonored and uncollected, the amount indicated on the invoice will be immediately due and payable, and further participation in this program may be terminated at the option of Indiana Beverage. I also understand that this program can be terminated by Indiana Beverage at any time. I agree to the terms. Date * MM DD YYYY Thank you!
