I authorize you, MENDOCINO COMMUNITY NETWORK, to initiate ACH Debits or Paper Drafts ("Debit Entries") to my deposit account ("Account") at my Financial Institution named below. This authorization is for the payment of recurring monthly amounts I owe MCN for Internet Services. IN ORDER TO TERMINATE OR REVOKE THIS AUTHORIZATION, I MUST NOTIFY MENDOCINO COMMUNITY NETWORK, THE ORIGINATING COMPANY, IN WRITING. So long as this authorization has not been terminated or revoked, any Debit Entry originated by Mendocino Community Network, under this authorization shall be conclusively presumed to be properly payable against my M.C.N. Account. I CAN STOP PAYMENT OF ANY SINGLE DEBIT ENTRY BY NOTIFYING MY FINANCIAL INSTITUTION 3 DAYS BEFORE MY DEPOSIT ACCOUNT IS CHARGED.
I understand that if there are insufficient funds in my Account when any authorized Debit Entry is presented, my Financial Institution may, at its discretion, pay or refuse to pay the Debit Entry, and may apply its usual returned check fees and charges. I also understand that if my Financial Institution refuses to accept a Debit Entry for any reason, Mendocino Community Network will not reprocess it without further written re-authorization from me.
I authorize my Financial Institution to charge these Debit Entries to my Account upon receipt and without advice to me.
My Financial Institution Name: __________________________________________________________
Street Address OR Branch: ______________________________________________________
City, State, ZIP: _______________________________________________________________________
Routing Number: ____________________________________________
My Checking Account Number: ______________________________________________
The Name(s) on the Account: _____________________________________________________________
Authorized Debit Entries: Mendocino Community Network is authorized to originate Debit Entries to my Account to pay recurring amounts I owe you in the FIRST WEEK of the month. The amount of these recurring payments may vary, however, no Debit Entry in any month may exceed the current amount owed to Mendocino Community Network. Please send all notices and advices to the email address shown below my signature.
I also authorize adjustment entries in the event of erroneous transactions to my account.
I hereby certify that I am an owner and authorized signer of the Account. I acknowledge receiving a copy of this authorization. Mendocino Community Network may supply a copy of this Authorization Agreement to my Financial Institution or to MCN's Bank upon request.
Date: _________________________ Signed: _________________________________________________
- email address:____________________________
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