I hereby authorize Teamsters Local 391 to initiate debt entries and initiate, if necessary, credit entries and adjustments for any debit entries in error due to my checking account indicated below and the depositrory (Bank) named to debit and/or credit the same such account. This authority is to remain in full effect until Teamsters Local 391 has received written notification from me of its termination in such time and in such manner as to afford Teamsters Local 391 a reasonable opportunity to act on it.

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First name:
Last Name:
Email Address:
Occupation:
Employer
Street
State
ZIP Code
Financial Institution
Account Type	Checking      Savings
City of Financial Institution
State of Financial Institution
Bank Routing Number
Account Number
Amount to Debit
Social Security Number
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