Cox Target Media / Valpak Direct Marketing Systems / Valpak Franchise Operations
805 Executive Center Drive West, Suite 100, Saint Petersburg, FL 33702

CONTACT INFORMATION

BANK INFORMATION

REMITTANCE INFORMATION

AUTHORIZATION

I authorize Cox Target Media or subsidiaries and the financial institution listed above to electronically deposit invoice payments into my bank account. If monies to which I am not entitled are deposited into my account by Cox Target Media or subsidiaries, I authorize Cox Target Media or subsidiaries to direct the bank to return said funds. This authorization will remain in effect until it has been cancelled in writing.