Automatic Payment Authorization Form
Name
*
First Name
Last Name
Email
*
example@example.com
Type of Bank Account
*
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
Name(s) on Bank Account (business name if used)
*
Routing Number
*
must be 9 numbers - no spaces
Account Number
*
must be 9-12 numbers - no spaces
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: