Customer Information

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Carrier Name

MC #

Factoring Company

I hereby authorize Transworth Logistics, Inc.

To Initiate

Debit/Drafts Credits/Payments

To My

Checking Account Savings Account

I understand that, if necessary, an adjusting debit or credit entry may be made to correct an error.
I also authorize the financial institution named below to credit and/or debit my account for the correcting entries. I duly certify that I am an authorized signer of said account and have the right to enter into this agreement.

Account Information

Name of Bank

City

State

Bank Routing Number

Account Name

Bank Account Number

Remittance Email

This authority will remain in full force and effect until such time as Transworth Logistics, Inc. has received written notification from me that the draft authorization has been revoked. It is further provided that written notification of termination, by either party, shall be provided in such time and manner as to afford either party reasonable opportunity to act on it.

Date