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Single Entry Written Authorization Form

I hereby authorize Appanasha Pet Clinic to initiate an electronic single debit entry withdrawal from my account with the indicated amount below for diagnostics, procedures, & care items. Furthermore, I assert that I am the owner or an authorized signer of this bank account.

Single Debit Entry Withdrawal Amount(Required)

The effective date of the withdrawal debit will occur on or after.(Required)

Type of Account(Required)

Checking Account

Savings Account

Financial Institution Name(Required)

Financial City and State(Required)

Name on Account(Required)

Routing Number(Required)

Account Number(Required)

NOTE: You may wish to request a voided check or in order to verifying that the routing and account number above are accurate and that the bank account is, in fact, in the name of the payer

Please sign and date the authorization below.

Signature(Required)

Date(Required)

If I have any questions or concerns in regard to this payment, or the payment does not occur on the date or in the amount authorized, or I wish to revoke this authorization, I can call 920-725-8307 during the following business hours Monday – Friday 8a-4p.

If you should need to notify us of your intent to cancel and/or revoke this authorization, you must contact us prior to the questioned debit being initiated. Please call 920-725-8307 or email [email protected]

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Name

This field is for validation purposes and should be left unchanged.