580 East State Street
Salamanca, NY 14779
Phone: (866) 945-5955
Fax: (716) 945-5956
www.salamancaoutlet.com
and return it to us.
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Salamanca Factory Cigarette Outlet 580 East State Street Salamanca, NY 14779 Phone: (866) 945-5955 Fax: (716) 945-5956 www.salamancaoutlet.com |
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Please print this form, read, fill out, sign, and return it to us. |
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I (we) hereby authorize Salamanca Factory Cigarette Outlet (AKA Salamanca Outlet) hereinafter to initiate debit entries, per our agreement in the contracts, to my (our) Checking Account, indicated below at the depository financial institution named below, and to debit the same to such account. I (we) acknowledge that the origination of AHC transactions to my (our) account must comply with the provisions of United States law.
Bank Name Branch:__________________________________________
City, State, Zip:______________________________________________
Routing Number ___ ___ ___-___ ___ ___-___ ___ ___
(Routing number is the first 9 digit number on bottom left of a personal check)
Account Number ____________________________________________
My Name as it appears on the checking account: _____________________________________________
My address as it appears on the checking account
__________________________________________________________
City, State, Zip:______________________________________________
My telephone number on this account: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
My Drivers License I.D. Number: _________________________________
The State the Drivers License is issued: ___ ___
DOB: ___ ___ / ___ ___/ ___ ___ ___ ___ Month / Day / Year
This authorization is to remain in full force and effect when I place a order, be it online or telephone with Salamanca Factory Cigarette Outlet. The debits may very in price on the transactions and the check number will change with every debit, until I send written notice to no longer debit this account.
Signature: ________________________________________ Date: _____________
Attach a check and a copy of your drivers license to the bottom of this ACH authorization and return by mail to Salamanca Cigarette Outlet
Place Check here:
Copy of drivers license here:
Attach a check and a copy of your drivers license to the bottom of this ACH authorization and return by mail to Salamanca Cigarette Outlet