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© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

July 4, 2010

Contact Name
Address
Address2
City, State/Province
Zip/Postal Code

OBJECT: AUTHORIZATION TO DEBIT ACCOUNT

Dear [CONTACT NAME],

This letter is to acknowledge that [COMPANY/INDIVIDUAL] is hereby authorized to debit our account no.
[ACCOUNT NUMBER] in the amount of [AMOUNT] for payment of [NATURE OF DEBIT]. Please
withdraw the funds from the following bank account:

Bank: [BANK NAME AND ADDRESS]

Bank Transit No: [BANK TRANSIT NO]
Account No: [ACCOUNT NUMBER]
Bank Tel. No. [BANK TELEPHONE NO]
Bank Contact [NAME OF BANK CONTACT & TITLE]

This shall be your good and sufficient authority for doing so. We enclose a blank check from the account
marked "VOID".

[NOTE: IF MORE THAN ONE SIGNATURE IS REQUIRED ON ACCOUNT, MAKE SURE BOTH BANK
SIGNING OFFICERS SIGN LETTER]

Sincerely,

Your name
Your title
(800) 123-4567
youremail@yourcompany.com

Company Name
Street, City, State/Province, Zip/Postal code Tel: (000) 000-0000 / Fax: (000) 000-0000
www.yourwebsite.com