ACH Authorization Application

Complete and submit this form to authorize ACH debits from your bank account.

Are you authorizing debits as a business or an individual?

Choose the option that matches the bank account being debited. Pick Business if the account belongs to a company or organization, or Personal if it's your own individual account. Only the contact fields for the option you choose will be required.

BusinessPersonal

Business information

Company name

Authorized contact name

Email address

Phone number

Billing address

City

State

ZIP

Bank account details

Bank name

Account holder name

Routing number

Account type

Account number

Confirm account number

Payment schedule

Amount (USD)

Frequency

Start date

Authorization

I authorize the company named above to initiate ACH debit entries to the bank account specified above for the amount and schedule listed. This authorization will remain in effect until I cancel it in writing. I understand that I may revoke this authorization by contacting the merchant at least 3 business days before the next scheduled debit.

I agree to the ACH authorization terms above and confirm the bank information is accurate.

Authorized signer name

Your information is transmitted securely and used only for processing ACH transactions.

Reminder: you selected Business — only the business contact fields above are required. You can switch the option at the top of the page if the account belongs to a different type of payer.