Customer Authorization Agreement for ACH Debit Direct Payments
Payor Name
*
This is the name of the Atlas Customer - it may or may not be the same as the name on the bank account
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
Primary Contact Title
*
Primary Contact Phone Number
*
Name on Account
*
This is the name on the bank account
Mailing Address
*
Street Address
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Bank Name
*
Routing Number
*
Account Number
*
Select Account Type
*
Checking Account
Savings Account
Attach a voided check image here.
*
Browse Files
Cancel
of
Signature
*
Printed Name of Signer #1
*
First Name
Last Name
Title of Signer #1
*
Date Signer #1 signed
*
Signature #2 (if more than one signatory on acct)
Printed Name of Signer #2 (if any)
First Name
Last Name
Title of Signer #2
Date Signer #2 signed
Submit
Should be Empty: