Royal Crest Dairy
350 S. Pearl St
Denver, CO 80209

Recurring Electronic Debit Authorization Form

I hereby authorize an automatic debit on the account designated for the Royal Crest Dairy invoiced amount each month.  My account will be automatically debited by an electronic bank draft on the 10th of each month for as long as I am a customer of Royal Crest Dairy.  I understand my balance is always available via Customer Service on the first of every month.  You will no longer have to write and mail us a check.  Simply complete the information below and mail to Royal Crest Dairy.  Any adjustments on your account, need to be done no later than the 8th of the month
PLEASE PRINT:
Customer #(if known):                          
Name On Account:
Service Address 1:
                                :     
City:                                                                   State:                           Zip:
Home Phone#:                                     Work Phone#:
Sample Check Information:
Susan Conrad                                                              995
123 Street                                                      _______20__
Columbus, OH 43222               
pay to the
order of  ______________________________________  $          

Bank Name
Bank Address

[:123456789     [:000074856599]:      0995
 *ABA or routing number is normally found in the bottom left corner of the check.  It is always nine digits long.
*Checking account number and is found near the center of the check.
*Check number, this number should match the check number in the upper right corner of the check.  The number can be located in the center or to the right.
*ABA#              *Checking Acct#        *Check#  Do not include micro code symbols [:
Please Enter YOUR Checking Account Information:
Bank Rtng No:                                   Checking Acct No:  
Bank:  
Please attach a voided check from your checkbook:
 

Attach Voided Check Here

 

 
In accordance with banking regulations, I understand that any drafts returned for insufficient funds will be billed to my Royal Crest account as a return fee of $25.00.
Signature: __________________________________              Date: ____________________  
Please be sure to:   1)Fill in all the information required    2)Sign and date the form   3)Attach a voided check
4)Mail to: Royal Crest Dairy, 350 S. Pearl, Denver CO 80209 -- Attn: Account Services