ACH Withdrawal Authorization
Name
*
Email
*
example@example.com
Name(s) on Bank Account
*
Bank Name
*
Bank Branch
*
City, State
Account Number
*
must be 9-12 numbers - no spaces
Routing Number
*
must be 9 numbers - no spaces
Type of Bank Account
*
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
Frequency
One Time
Monthly
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (if monthly)
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Amount
*
In US Dollars
Purpose
*
Enrollment Fee, Tuition, Donation, etc.
Signature
*
Enter the message as it's shown
*
Submit
Submit
Should be Empty: