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

SmokersRoundup.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 SmokersRoundup.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.

Please Mail or Fax this document to:

SmokersRoundup.com

P.O. Box 365

Irving, NY 14081

OR

Fax # (206) 203-4555

NOTE: Our fax machine only receives one document at a time. Multiple pages will be compressed into one file and become un-readable. Please Fax your Authorization Form first as a separate document, then redial the Fax number again and Fax a Copy of your Drivers License & Bank Voided Check.