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
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Customer Phone
Customer Phone
*
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Holmes Security Customer Number
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.