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.

* Our Accounts Receivables department will be contacting you to obtain banking information to complete your ACH setup.

Terms selected are subject to credit approval.

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