Direct Payment Form

Thank you for agreeing to pay using Automatic Payment. Electronic payments save time and you will enjoy the convenience. Banking rules require your approval to collect monthly payments in this manner. The approval is active until you notify us to stop using Automatic Payment.

Automatic Payment is safe, efficient, and consumer friendly. Banking laws protect consumers from someone taking money from your account in an unauthorized manner.

Direct Payment Authorization

I hereby authorize Ford’s Fuel Service and/or Ford’s Propane Gas Inc. to initiate entries to my checking or savings account at the financial institution listed below. This authority will remain in effect until five days after I provide written notice to cancel it.
Your Details
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Bank Details
Name
First
Address
Street Address Address Line 2 City State ZIP Code
Routing Number (see sample below)
Account Number (see sample below)
Date
Signature
(Please attach a copy of a “Voided” check- deposit slips will not work)
Please upload an image of your void check*
Accepted file types: jpg, png, pdf, gif.

Direct Payment Authorization

Your Details

Bank Details

Our Locations

Loris

North Myrtle Beach

Oak Island