Order Propane and Bulk Fuel

Bank Name

City

Zip

Routing #

Bank Account Type

CheckingSavings

I authorize my employer, Cross Petroleum Service, and its Agents, including Financial Institutions, to initiate
electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my checking and/or savings accounts listed above. This authorization will remain in effect until I have informed my employer in writing that I wish to cancel it and my employer has had reasonable time to effect such cancellation.

Date

Online Propane/Bulk Fuel Request