Old Father Time
116-C Ballast Rock Road
Powells Point, NC 27966

USA

E-Check Authorization Form


I authorize Old Father Time, LLC to draft my checking account as follows:



Name
(as it appears on your bank statement)
Address            
(as it appears on your bank statement)
Add'l. Address

City
  State   Zip + 4


Bank Routing Number 
(9 Digit Bank Identifying Number)

Phone Number
(Your bank may call you to verify)

Bank Account Number 
(Your checking account number)

Amount to be Drafted
  in payment for OFT Order #

Type of Account (check one)

  Consumer Checking
  Consumer Savings
  Business Checking
  Business Savings


     
Signature                                                                                                                                    Date


                                               

Please Complete this Form on your screen, then print it and send by fax (1-800-783-4177) or email attachment to watchmakers@oldfathertime.com