I (we) hereby authorize AKRS E
QUIPMENT hereinafter called COMPANY, to initiate credit
tries to my (our) account indicated below and the financial institution named below, hereinafter
called FINANCIAL INSTITUTION, to credit the same to such account for ___________________________
I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the
provisions of U.S. law.
Financial Institution Name Branch
________________________ Type of Acct: Checking Savings
This authority is to remain in full force and effect until COMPANY has received written notification from
me (or either of us) of its termination in such time and manner as to afford COMPANY and FINANCIAL
INSTITUTION a reasonable opportunity to act on it.
Please provide an email address for
payment notification: ______________________________
Printed Individual Name Signature
Printed Individual ID Number Date
PLEASE ATTACH A VOIDED CHECK TO THIS FORM.