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MCN Bank Authorization Form

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Mendocino Community Network

Authorization Agreement for Direct Payments

                                               (ACH Debits or Paper Drafts)          click here to download PDF

Please Print This Form, Complete, and Mail to MCN, along with a Voided Check
PO Box 2445
Mendocino, CA  95460
707-937-1444    Fax: 707-937-0733
(Your Bank will notify you 10 days before the amount is debited from your account)

For MCN Only Plat ID:________ Fusion: Y / N External: _______

 Mendocino Community Network Authorization Agreement for Direct Payments (ACH Debits or Paper Drafts )
Please Complete this form , and return to MCN, along with a Voided Check :
1. By Mail: PO Box 2445, Mendocino, CA 95460 707 - 9 37 - 1444
 2. By Fax: 707 - 937 - 0733
3. By Email: Send scan of completed form and voided check to This e-mail address is being protected from spambots. You need JavaScript enabled to view it
4. In Person to the MCN Office: 10700 Ford St. Mendocino CA 95460

 I authorize you, MENDOCINO COMMUNITY NETWORK ( “ MCN ” ) , to initiate ACH Debits or Paper Drafts ("Debit Entries") to my deposit account ("Account") at my Financial Institution named below. This authorization is f or the payment of recurring monthly amounts I owe MCN for Internet Services. I N ORDER TO TERMINATE OR REVOKE THIS AUTHORIZATION, I MUST NOTIFY MCN , THE ORIGINATING COMPANY , IN WRITING. So long as this authorization has not been terminated or revoked, any Debit Entry originated by MCN , under this authorization shall be conclusively presumed to be properly payable against my M C N Account. I CAN STOP PAYMENT OF ANY SINGLE DEBIT ENTRY BY NOTIFYING MCN OR M Y FINANCIAL INSTITUTION 3 DAYS BEFORE MY DEPOSIT ACCOUNT IS CHARGED .
I understand that if there are insufficient funds in my Account when any authorized Debit Entry is presented, my Financial Institution may, at its discretion, pay or refuse to pay the Debit Entry, and may apply its usual returned check fees and charges. MCN may also charge a bounce payment fee. I also understand that if my Financial Institution refuses to accept a Debit Entry for any reason, MCN will not reprocess it without further re-authorization from me. I authorize my Financial Institution to charge these Debit Entries to my Account upon receipt and without advice to

My Financial Institution Name: __________________________________________________________

Street Address OR Branch: ______________________________________________________

City, State, ZIP: _______________________________________________________________________

Routing Number: ____________________________________________

My Checking Account Number: ______________________________________________

The Name(s) on the Account: _____________________________________________________________

Authorized Debit Entries: MCN is authorized to originate Debit Entries to my Account to pay recurring amounts I owe you in the FIRST WEEK of the month for Fusion customers and 15 th of the month for all other customers . The amount of these recurring payments may vary; however, no Debit Entry in any month may exceed the current amount owed to MCN . All notices and advices will be sent to the email address on my MCN account . I also authorize adjustment entries in the event of erroneous transactions to my account. I hereby certify that I am an owner and authorized signer of the Account. MCN may supply a copy of this Authorization Agreement to my Financial Institution or to MCN's Bank upon request

Date: _________________________

Signed: _________________________________________________

              email address:____________________________

Questions? Send email to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it  
Copyright 2017

Last Updated on Wednesday, 20 September 2017 10:32  

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