Debit Authorization Form

Worldwide Travel, Inc. Agent Name:
Extension:
Worldwide Travel, Inc. ACH Reference ID:

I(We) hereby authorize Worldwide Travel, Inc., here in after called Worldwide Travel, to Initiate debit entries and to initiate, if necessary, adjustments for any debit entries in error to my(our)

Please check one:
Checking Account
Saving Account
Indicated below and the depository named below, here in after called DEPOSITORY, to debit to such account in the amount of $

DEPOSITORY (Bank Details)

Name:
Branch:
Address:
City:
State:
Zip:
Transit / ABA Number:
Account Number:
Voided check Number(For ACH Authorization):

This authority is to remain in full force and effect until Worldwide Travel has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Worldwide Travel and DEPOSITORY a reasonable opportunityto act on it.

Name:
Date:
Last
First
Middle
Id Number
Signed