Bank Account / ACH Authorization Form
Please fill in each item
Is this a troop or service unit bank account?
Is this a troop or service unit bank account?
*
Troop
Service Unit
Troop Number
*
Service Unit Number
*
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Bank Information
Is this a checking or savings account?
Checking
Savings
Bank Name
*
Please Select
Charter Center
Wells Fargo
Regions
Trustmark
Synovus
Other
Name of Bank
*
Bank Routing Number
*
Bank Account Number
*
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Who is on this account?
Are you the troop's main point of contact for financial concerns?
*
Yes
No
Who is the troop's main point of contact for financial concerns?
*
Name and contact information for troop treasurer.
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
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Other People
List ALL authorized signers on this account.
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Who else has access to this account?
List name of each co-signer on the account.
Other People End
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ACH Authorization
ACH Authorization
I hereby authorize Girl Scouts of Southern Alabama to initiate credits and/or debits to this account as they deem necessary, and for the financial institution named earlier to credit and/or debit my account for the amounts requested by Girl Scouts of Southern Alabama. I understand that an adjusting debit or credit entry may be made to correct an error. I also authorize the financial institution named earlier to credit and/or debit my account for the correcting entries. I duly certify that I am an authorized signer of said account and have the right to enter into this agreement. This authority will remain in full force and effect until such time as Girl Scouts of Southern Alabama has received written notification from me that the draft authorization has been revoked. It is further provided that written notification of termination, by either party, shall be provided in such time and manner as to afford either party reasonable opportunity to act on it.
I Agree
*
Yes
Name
*
First Name
Last Name
Signature
*
Left click and hold your mouse button to sign your name
Date
*
-
Month
-
Day
Year
Date
Authorization end
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