Maverick Distribution ACH Add/Update Request
This form will require a picture of a voided check or ACH instruction sheet from your bank. Please have available when filling in this form.
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
*
Voided Check or Bank ACH Instructions
*
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. We will charge you $35 for each return by a bank or other depository institution of a dishonored check, negotiable order of withdrawal or ACH.
Submit
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