Auto-Draft Payments

Customer Application Form / Checking Account

 

Save time & money by signing up for our new Automatic Payment Plan (APP). For your convenience, we can now automatically deduct your monthly bill from your checking account. No more checks to write! No more bills to open. No more stamps to lick. Simply complete the information below and attach a voided check.

Name*

 

 

Date*

 

Address*

 

City*

 

State

 

Zip Code

 

Phone Number*

 

E-Mail Address

 

 

 

PLEASE ATTACH A VOIDED CHECK TO THIS FORM

 

NOTE: If you bank at a Credit Union, you must verify with your institution the correct bank routing and account numbers for use with pre-authorized drafts on your account.

 

I hereby authorize a bank draft on the account designated above, not to exceed the amount due Hall Oil & Propane according to product and services delivered by Hall Oil & Propane to me. You must sign one (only one) of the next two (2) boxes.

 

 

I would like for Hall Oil & Propane, Inc. to automatically draft my fuel payment from this account after each delivery. *

 

                                                                                  date_____      _

 

I would like for Hall Oil & Propane, Inc. to automatically draft 12 (one per month) equal payments from this account. *

 

                                                                                  date_____      _

 

Everything below is to be filled in by Hall Oil & Propane Inc. from data on voided check.

Banking Information

Name of Primary Bank

 

Name of Account

 

Bank Representative

 

Bank Phone Number

 

Bank Routing Number

 

Bank Account Number

 

Text Box: For Office Use Only Start Date: / / Starting Balance: $ Payment Requested: $ + Service Charge: $ = Total Monthly Draft Amount $