​Bank Draft Authorization

​I,_______________________hereby authorize mindFULL, P.A., hereinafter called COMPANY, to initiate debit entries to my account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
 
 
________________________________________________________________________
Financial Institution Name                                                                         Branch Location
 
________________________________________________________________________
Address                                                           City/State                                     Zip
 
_________________   _____________________   Type of Acct: ____Checking ____ Savings
 Routing Number         Account Number
 
 
This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. A 60-day written notice is required.

 
_______________________________                      ________________________________
Print Individual Name                                               Signature
 
_______________________________                      ________________________________
Date                                                                            Date debits to start/AMOUNT/Initials
 
 
 
PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM