Check Writing Information Form

In order for us to accept checks from any company, we must ask for the following information.  This information will be held in confidence by Deakins Pond Wholesale Nursery and will not be used for marketing purposes or distributed in any other way.  This information can be used to protect Deakins Pond Wholesale Nursery as well as your company by having authorized check signers on file with us.  Thank you for your cooperation.

Check Authorization Information:

Full Name of Person Signing Company Check(s):  ____________________________________________

Home Address (if different than business):                Street________________________________City____________________ State____Zip______

Home Phone#:___________________

Driver's License#:_________________ State of Issue:____________________

Please include copy of Driver's License with this application.

Date of Birth: _________________Sex:_______Height:________

 

I agree that the above information is true to the best of my knowledge and that I am authorized to write checks for the company I work for:

 

_________________________________                        _________________________________

                Signature of Applicant                                                                   Print Name