DIRECT DEPOSIT / DEBIT AUTHORIZATION FORM

Personal Information

Full Name(Required)

Phone(Required)

Email(Required)

Billing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Bank Account Information

Bank Name(Required)

Account Type(Required)

Checking

Saving

Name on Account(Required)

Routing Number (9 digits)(Required)

Account Number(Required)

Authorization

I authorize AvMar Accounting to initiate electronic credit entries to the account listed above and, if necessary, debit entries and adjustments for transactions made in error. I confirm that I am the authorized account holder and that the information provided is accurate. This authorization remains in effect until written notice of termination is provided with reasonable time to process.

Signature(Required)

Printer Name(Required)

Date