First Name *

Last Name *

Phone *

Email *

Please choose your charge account limit *

$250

$500

$1000

I authorize Orcas Food Co-op to charge transactions and/or apply credits to this charge account for orders I place through Orcas Food Co-op online shops (retail shop and Provisions Co-op Wholesale orders). *

Yes I agree to the terms listed above

I accept full responsibility for all charges made to my account. If I dispute any charges that are on my account, I agree to notify OFC within 5 business days of receiving the e-receipt. *

Yes I agree to the terms listed above

I agree to receive statements and receipts by email and will provide the Co-op with a valid e-mail address to receive e-receipts for purchases charged to my account. *

Yes I agree to the terms listed above

I agree to electronic withdrawal of funds from my bank account to pay my charge account balance in full. My charge account payment will be withdrawn in full on Thursday each week. If sufficient funds are not available for withdrawal on the date OFC debits my account, I will be charged a fee of $25 for the first NSF occurrence, $35 for the second NSF occurrence, and my charge account will be terminated after the third NSF occurrence. *

Yes I agree to the terms listed above

I understand that OFC reserves the right to terminate any and all customer charge accounts at any time as deemed necessary or appropriate at its sole discretion. *

Yes I agree to the terms listed above

This agreement will be in effect until either party terminates the agreement by written notice to the other party. *

Yes I agree to the terms listed above

Bank Account Information

Bank Account Type *

Checking

Savings

Bank Name *

Account Number *

Bank Routing Number *

The bank account listed above is: *

My personal bank account

The bank account of my spouse or domestic partner

If the bank account listed above is not my own personal account, I have received permission to use the bank account listed for this purpose. *

Yes, I have permission to use the bank account listed above.

I am the primary owner of the bank account listed above.

ACH Transfer Authorization

I hereby authorize Orcas Food Cooperative (OFC) to send debit entries (and credit and adjustment entries as needed), electronically from my account indicated above. This authorizes the financial institution holding the account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable US Law. This authorization will be in effect until Orcas Food Cooperative receives a written termination notice from myself and has a reasonable opportunity to act on it. *

Yes I agree to the terms listed above.

The undersigned authorizes Orcas Food Cooperative to initiate debit and or credits by electronic transfers to the account designated above *

Title of Authorized Person

Signature *

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