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*First or One Time Fee:
*Recurring Thereafter:
Account Type:
*Routing Number:
*Account Number:
*First Name:
*Last Name:
*Address:
*City:
State:
*Zip Code:
*E-Mail:
*Cell Phone:
I authorize ProTidy Services Incorporated to initiate credit or debit entries to my bank account listed above after (never before) each service for the amount indicated. This authority is to remain active until ProTidy Services Incorporated has received notification from me. The credits and debits pursuant to this agreement will be processed through the Federal Reserve Automated Clearing House (ACH) system.
*Type "YES" To Accept:
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