Auto-Debit Enrollment

Customer Information

Account Number

Full Name *

Street Address *

City *

State *

ZIP *

Phone

Bank Account Information

Account Type *

Checking

Savings

Routing Number (9 digits) *

Bank Account Number *

Confirm Bank Account Number *

Authorization Agreement

By checking the box below, I authorize QCOL Inc to initiate electronic debit entries to my bank account indicated above for the balance due on my account. I understand that this authorization will remain in effect until I notify QCOL Inc in writing that I wish to revoke it, and I allow reasonable time for QCOL Inc to act on my revocation.

I authorize automatic debits from my bank account for balances due and understand I may cancel at any time.

✓

Enrollment Complete!

Your auto-debit enrollment has been successfully processed. You will receive a confirmation email shortly.