Attention First Time Customers

All new customers are required to mail or fax a copy of their Drivers License and this form filled out and signed before their product will be shipped

AUTHORIZATION FORM

Smokinfree.com

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

Yes, I would like to take advantage of the security and convenience of electronic funds transfer for periodic payments.

As a duly authorized check signer on the financial institution account identified herein, I authorize Smokinfree.com to perform scheduled or periodic electronic funds transfer debits from my checking account, and apply electronic funds transfer credits to same.

I understand and authorize all of the above as evidenced by my signature below.

Print Name_______________________________

AUTHORIZING SIGNATURE: ________________________ ___DATE: ____________

Checking Account Information

Enter financial institution account information into the fields provided below or attach a blank VOID check.

Complete or attach Blank VOID Check here.	Financial institution:	Branch:
	City:	State:	ZIP CODE:
	Transit/ABA #	Account #

Please Fax this document to: (888) 236-5167