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Authorization Agreement for Automatic Debit on Checking Account

Name :
Street Address :
City, St, Zip :
Email Address :




I hereby authorize Hazleton Online to automatically debit payment

Name As It Appears on Check:
Routing #
Bank Account #
Bank Name





Payment would appear on your Bank statement with the name HazOnline. Automatic deductions require signed authorization. (Please note we will not continue to deduct without signed authorization form on file) Form needs to be returned within 30 days for automatic deduction to take effect. If you wish to cancel Automatic Debit for your account we will need a written statement from you.

I agree to above terms & conditions.

Signature : ____________________________ Date : _____________

Mail To: Hazleton Online  PO Box 36  Hazleton, PA 18201-0036

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