1. Bank Draft Request Form
Name of Account Holder Account Number
Bank Routing Number
Bank Address
I hereby authorize Hest Technologies* to initiate debit entries to my bank account and the depository (bank or credit union)indicated
above. This authority is to remain in full force and effect until Hest Technologies and the specified Depository have received written
notification from me of its termination. I understand that the debit to my account will occur on a weekly basis for applicable data management
and/or phone time fees and that I will receive a notice when a draft has been initiated.
Account Holder's DATE
Signature
Please Print Name
* Bank draft will show as PrePaid Planet, Trip Wire Entertainment, or Get Connected of which Hest
Technologies is the parent company.