Billing Change Notification Form

Billing Change Notification Form

Organization Name	Organization ID Number
Address
City	State	Zip
Contact Person	Home Phone	Work Phone

New Bank Account Information
Use the space below to provide Great Lakes Scrip Center with your new bank account information Please provide all requested information and attach a void or cancelled check to this authorization so that Great Lakes Scrip Center, Inc. can verify the accuracy of your depository account and routing numbers. Sorry, but GLSC cannot accept check payments from personal bank accounts. Your check payment must be drawn on an account in the name of your non-profit organization. Your bank account change cannot be processed without a copy of a voided or cancelled check from your new account.

Bank		Bank Phone
City		State	Zip
Bank ABA Routing #	Bank Account #		Account Type (check one) [ ] Checking [ ] Savings

I (we) hereby authorize Great Lakes Scrip Center, Inc., hereinafter called COMPANY, to initiate debit entries to my (our) Checking account indicated above at the depository named above, hereinafter called DEPOSITORY, to debit same such account. This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name of authorizing person	Title
Signature	Date

Note: All written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.

Mail (do not fax) this completed form to:
Great Lakes Scrip Center, Inc.
P.O. Box 8158
Kentwood, MI 49518-8158