ACH Debit Authorization

I (we) hereby authorize Midwest Veterinary Supply, Inc to initiate debit entries to my (our) checking account indicated below at the depository financial institution named below.

This authorization is to remain in full effect until Midwest Veterinary Supply, Inc has received written notification from me of its termination.

Furthermore, if any such electronic debit(s) should be returned by my financial institution as Non-Sufficient Funds (NSF), I authorize MVS to collect a returned item fee from my account.

Note: This is a permanent change and all subsequent payments will be handled through electronic payment.

I understand and authorize all of the above.

Customer Number:

Your Company Name:

Your Name:

Your Phone Number:

Your Email:

Financial Institution:

Branch Name:

City:

State:

Zip Code:

Routing Number:

Confirm Routing Number:

Checking Account:

Confirm Checking Account:

Please check one of the following options for automatic ACH withdrawal:

Yes, ACH automatic withdrawal for each invoice
(Each invoice is debited separately and automatically at the time of shipment.)

ACH automatic withdrawal on the 10th of each month
(Your MVS statement balance amount will automatically be withdrawn from your
checking account on the 10th of each month.)

Terms selected are subject to credit approval.

If you have any questions please contact your primary distributor location:

Minnesota and Texas
Dana Marcus at 952-567-6885 | email: dana.marcus@midwestvet.net
Wisconsin and Iowa
Dana Quint at 952-567-6263 | email: dana.quint@midwestvet.net
Indiana or Pennsylvania
Melissa Braun at 952-567-6861 | email: melissa.braun@midwestvet.net
Las Vegas
Martha Martinez at 952-567-6271 | email: martha.martinez@midwestvet.net

Check the Box: