AUTOMATIC WITHDRAWALS


 

 

COMPANY NAME:                                                   

I,                                                    as the authorized agent of Company, above, hereby authorize PreCheck Health Services,
nc.
, Secured Party, or its assigns, to initiate, on a monthly basis, debit entries and to initiate,
if necessary, credit entries and adjustments for any debit entries in error to our account
indicated below and the financial institution named below. I also authorize PreCheck Health
Services, Inc.
, Secured Party, or its assigns, to initiate a one-time debit for the deposit
(Applied to Advance Payment(s), Documentation Fee, Site Fee and other fees).

 

 

FINANCIAL INSTITUTION:           

TRANSIT/ABA NUMBER (lower left corner of check, 9 numbers):  

BUSINESS NAME ON ACCOUNT:   

CHECKING ACCOUNT NUMBER:    

 

This authority is to remain in full force and effect until PreCheck Health Services, Inc.,
Secured Party, or its assigns has received the full sum ofmonies owed. We understand
that our withdrawal of this authority without the express written consent of PreCheck Health
Services, Inc.
, Secured Party, or its assigns shall constitute a default of the finance agreement
for which this payment is being made. We also understand that if we have supplied a copy of a
check, bank statements or any other form of bank verification, then PreCheck Health Services,
Inc.
, Secured Party, or its assigns shall withdraw funds from the account number and routing
number listed on the check, bank statements or any other form of bank verification.
An electronic version of this document with signature shall be considered an original.

 

                      

       PRINTED NAME                          TITLE           DATE


 

Leave this empty:

Signed by Francis Pittilloni
Signed On: December 6, 2021

Signature Certificate
Document name: AUTOMATIC WITHDRAWALS
Unique Document ID: 2b112f4e5726541b9cc4178d420fbd3d4fc8cbbf
Timestamp Audit
December 6, 2021 8:19 pm ESTAUTOMATIC WITHDRAWALS Uploaded by Francis Pittilloni - francis@precheckhealth.com IP 162.197.167.85