Payment Withdrawal Authorization Form


Credit/Debit Card Automatic Payment Withdrawal Authorization Form

A. Borrower’s Information

Full Name:

B. Billing Information (Credit/Debit Cards) – Please complete this section if you have chosen to have your payments automatically processed via Credit/Debit cards each period
Name on Card:    
Mailing Address:  City :  State:  Zip:   
Credit/Debit Card Number: 
Card Type: 

Card Expiration Date:  Card Verfication Code: 

C. Automatic Withdrawal Frequency & Amount

Authorized withdrawal amount:   
Frequency: 

Starting Date(s) 

Sign Date:

I Authorize Kings Enterprises INC to automatically process payments and late fees from my above listed Credit /Debit Card on the frequency and dates selected in section C plus a administrative fee. I understand that I am authorizing this card to be put on file on my loan account. I also understand that this card will be billed for my due payments.

Mailing Address:
Kings Enterprises INC
505 North Garden St
Columbia, TN 38401

Credit/Debit Card Automatic Payment
Withdrawal Authorization Form
Account: OL-

Leave this empty:

Kings Firearms and More http://kingsfirearmsandmore.com
Signature Certificate
Document name: Payment Withdrawal Authorization Form
Unique Document ID: 7b5c95bb4fd14bfdc63e933367fa7e147950e868
Timestamp Audit
2017-07-12 10:56:48 CDTPayment Withdrawal Authorization Form Uploaded by John King - webforms@kingsfirearmsandmore.com IP 76.9.175.250