Electronic Funds Transfer Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Financial Institution InformationName of Bank *Bank AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNine-Digit Routing Transit Number: *Account Name: *Account Number *I do hereby give permission to CYCLE CITY PROMOTIONS to electronically deposit funds into my bank account. I also agree that if I receive funds that were not intended for me, that I will return the money as soon as possible. *I agreeBy checking 'I agree' you are acknowledging the above information and consent that this is also your 'electronic signature'.Submit