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ACH Credit/Debit Authorization Form
Financial Institution Information
Name of Financial Institution
(*)
Branch Address
(*)
Branch City
(*)
Branch State
(*)
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District Of Columbia
Delaware
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
Branch Zip
(*)
Customer Information
Customer Name
(*)
Customer Business Name (
If Applicable
)
Customer Address
(*)
Customer Phone
(*)
Customer Email
(*)
Customer Contact Name
(*)
Routing Information
Type of Bank Account
(*)
-- Select Account Type --
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
ACH Set Amount $
Or Maximum Amount $
Financial Institution Routing Number
(*)
Checking/Savings Account Number
(*)
These numbers are located on the bottom of your check as follows:
Terms & Conditions
I (we) hereby authorize Allpro Technology LLC (THE COMPANY) to initiate entries to/from my (our) checking/savings accounts at the financial institution entered (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 (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.
BY CHECKING THE "I ACCEPT THE TERMS & CONDITIONS ABOVE" CHECKBOX AND ENTERING MY NAME BELOW, I CONFIRM THAT I HAVE READ, UNDERSTAND, AND AGREE TO BE BOUND BY THESE TERMS AND CONDITIONS.
I ACCEPT THE TERMS & CONDITIONS ABOVE
(*)
Name of authorized representative:
(*)
Today's Date:
Submit ACH Form
