Name(s):         Phone Number:

Address:

City:     State:     Zip:

Bank Name: FNB Bank, Inc.     Transit/ABA# 083901087    Address: 101 East Broadway Mayfield, KY 42066

Bank Account Number*:   *voided check or deposit slip attached

Vendor Account Number:

    I (we) authorize (herein referred to as "Vendor") and FNB Bank, Inc. to initiate variable entries to my bank account listed above. This authorization will remain in effect until I notify Vendor in writing to cancel it in such time as to afford Vendor a reasonable opportunity to act. Also I agree that I remain obligated to pay for these services in the even that a charge to my account is dishonored, for whatever reason, and that Vendor retains its normal collection rights.

_________________________________         _________________________________

Signature of account holder                                  Date

Print this form out first then sign and date and return to us at:

FNB Bank, Inc.

101 East Broadway

P.O. Box 369
Mayfield, KY 42066-0029