Electronic Payment Authorization (No charge will be made at this time)

Your Name*
First Name Last Name
Your Email Address*
Business Name*
Account Type*
- Checking
- Savings
Account Use*
- Business
- Personal
Bank or Credit Union Name*
Accountholder's Name*
Account Number*
Sample shared at the bottom to help you find account number
Routing Number*
Transit / ABA Number

sample check

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