ROUTE 51 SOUTH · P.O. BOX 445 · PERRYOPOLIS, PA 15473

PHONE: (724) 736-4445 · 1-800-735-5288 · FAX: (724) 736-0466

 

 

 

 

 

 

BANK AUTHORIZATION

 

 

 

 

 

 

            The undersigned, _____________________________________________

 

            hereby authorizes you and your assigns or any other agency employed by

 

either of you.  To disclose to this interested party your experience with the

 

undersigned accounts.

 

 

 

 

                                   

 

__________________________________________

                                    Customer Signature

 

 

 

 

Bank Name:     __________________________

 

Account #:        __________________________

 

Opening date:   __________________________

 

Average bal:     __________________________

 

NSF:    ________________________________

 

Rating:  ________________________________

 

Rep signature:   __________________________