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I authorize TRINITY SITE SERVICES (THE COMPANY) to initiate transactions for my (our) checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION). If needed, THE COMPANY may also correct any transaction errors. This authorization will remain active until I (we) notify THE COMPANY in writing to cancel it, allowing them and THE FINANCIAL INSTITUTION enough time to act.

Bank

Account Name

First Name

Last Name

Billing Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Account Type

Routing Number

Account Number

Confirm Account Number

Maximum Amount (per charge):

$

Please Sign

Date

MM

DD

YYYY

These numbers are located on the bottom of your check as follows:

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