Link to PDF of this form CLICK HERE

To manually fill out form use the PRINTABLE PDF FORM… CLICK HERE

Then fax to us at 850-574-3788



Click or drag a file to this area to upload.

* Terms & Conditions

The above-named customer hereby authorizes Eli Roberts and Sons, Inc. to initiate electronic funds transfers
(EFT) from the bank account of the Financial Institution named below for withdrawal of funds to effect
payments due— “Debit Entries” and/or correction entries.

The customer agrees to maintain sufficient funds in the above-designated bank account to pay EFT Debit
Entries when initiated. The customer understands that this authorization will remain in effect until they notify
Eli Roberts and Sons, Inc. in writing at the above address, and the above financial institution that they no
longer desire this service, allowing reasonable time to act on this notice.

All other terms and provisions of other agreements between customer and Eli Roberts and Sons, Inc. remain
in effect, except as expressly provided herein.