Name:

Address:

Phone Number:

Credit Union Name: POWERCO Credit Union - Routing # 244077093

Credit Union Address: 471 Morrison Road, Suite M, Gahanna, OH 43230

Credit Union Account Number: Checking Savings

Vendor Account Number:

I (we) authorize and POWERCO Credit Union to initiate variable entries to my checking/savings account. This authorization will remain in effect until I notify in writing to cancel it. Also I agree that I remain obligated to pay for these services in the event that a charge to my account is dishonored, for whatever reason, and that retains its normal collection rights.

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Signature

*Include voided check or deposit slip with this form when sending to vendor.