Maverick Distribution ACH Add/Update Request

Maverick Distribution ACH Add/Update Request
LEGAL BUSINESS NAME *
STORE NAME (if applicable)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CONTACT NAME *

First Name Last Name
PHONE *

Area Code Phone Number
EMAIL *
example@example.com
BANK INFORMATION

ACH Drafts are drafted every Tuesday for all previous weeks invoices (M-F)
BANK NAME *
BANK PHONE

Area Code Phone Number
BANK EMAIL
example@example.com
NAME ON ACCOUNT *
ROUTING NUMBER *
ACCOUNT NUMBER *
AUTHORIZED SIGNER NAME *

First Name Last Name
AUTHORIZED SIGNER TITLE *
SIGNATURE *

By signing ABOVE, I attest the above information is correct and that I am an authorized representative of said company and able to open accounts on behalf of said company. If ACH information has been provided, I also authorize Maverick Distribution to create an ACH Draft for invoice payment. Clear
Should be Empty:

BANK INFORMATION