ACH Authorization Form
Squash and Education Alliance (SEA)
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Tax ID Number
*
Social Security Number / Employer Identification Number
Depository Bank Name
*
Name On Account
*
Account Type
*
Checking
Savings
Account Purpose
*
Personal
Business
Account Number
*
Routing Number
*
Signature
*
I hereby authorize Squash and Education Alliance (THE COMPANY) to initiate entries to my checking/savings account at the financial institution listed above (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: