ACH WIRE TRANSFER FORM

Customer Name:_______________________________________

Address:______________________________________________

City:_____________________State: ____________Zip:________

Fax:______________________Phone:_____________________

Tri-Mart Corporation Customer Number(s): list all that will be ACH’d

1.

2.

3.

4.

5.

Bank Information:

Name of Bank:________________________________________

Address:______________________________________________

City:_____________________State: ____________Zip:________

Phone Number of Bank:________________________

Contact Person:_______________________________

Bank Account Number:_________________________

Bank Account Type (Checking/Savings)___________

Bank Routing Number:_________________________

I authorize Tri-Mart Corporation to wire money out of my account(s) listed above, for my account receivable balance every ________ days from receipt of merchandise. I understand by signing I also agree that if I stop any wires, my account may go onto “cash on delivery” from that day forward.

____________________________ ____________________________

Signature Date

____________________________ ____________________________

Title Phone Number