Alfred J. Villavecchia
				Buying Group - Since 1980

Corporate Office						Billing Inquires
P.O. Box 129							Phone:	203.968.1745
Montvale, NJ 07645-0129						www.villavecchia.com
Phone:	201.573.0830 		     	     Email: customerservice@villavecchia.com
Fax:	201.573.0380


Date: ___ / ___ / _______


This is to inform Alfred J. Villavecchia Corp. that I wish to have 

$ ______________ . ___ electronically debited on ___ / ___ / _______

from my bank account.

(There is a $3.00 processing fee for transactions under $300.00)


Business Information:

Group Account # : _________

            Name: ___________________________________________________________

         Address: ___________________________________________________________
         
            City: _______________________________  State: ___  Zip: _________

           Phone: _____ - _____ - _________
           
           Email: ___________________________________________________________



Bank Information:

       Bank Name: ___________________________________________________________
       
  Routing Number: ___________________________________________________________

  Account Number: ___________________________________________________________

     Accout Type: Checking / Saving (circle one)
 	     
 	     
 	     
      Print Name: ___________________________________________________________


       Signature: ___________________________________________________________



	Please fax to 201.573.0380 or email customerservice@villavecchia.com