Automatic Bank Draft Form

By submitting this form you authorize regularly scheduled charges to your checking/savings account. You will be charged the amount indicated on your statement for each billing period. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
Name Name * First Last
Company Name (If a Business Account)
Type of Account *

Type of Account Checking Savings
Customer Address Information Customer Address Information *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Customer Phone Customer Phone * - ### - ### ####
Name of Bank or Credit Union *
Routing Number *
Account Number *
Signature: Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Holmes Electric, Inc., dba Holmes Security Systems, in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I understand that the transaction will occur between the 25th and 28th of the payment month. For ACH debits to my checking/savings account, I understand that because they are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF) or a closed account, I understand that a fee will apply. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long long as the transactions correspond to the terms indicated in this authorization form.