Authorization - Bow Street Beverage

Date(Required)

Business Name(Required)

Corporate Headquarters or Legal Name (if different)

Maine Liquor License #(Required)

Contact Person(Required)

Email(Required)

Phone(Required)

Preferred Email for Notifications(Required)

Banking Information

Name of Financial Institution(Required)

Location (City, State)(Required)

Financial Institution's Routing/Transit Number(Required)

Checking Account Number(Required)

Please attach an image of a cancelled or voided check. (JPG, PNG or PDF)(Required)

Accepted file types: jpg, png, pdf, Max. file size: 8 MB.

I hereby authorize Bow Street Beverage and Bow Street Beverage Wells to initiate a debit entry to my checking/savings account at the banking institution indicated above, and initiate adjustments (if necessary) for any transactions debited in error. This authority will remain in effect until Bow Street Beverage is notified by me in writing to cancel it.

Name(Required)

Title(Required)

CAPTCHA

Electronic Fund Transfer Authorization

Title

Banking Information