DIRECT DEPOSIT FORM (ACH CREDITS)

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)
Choose type of Request*

ADD (New Participant)CHANGE (Financial Institution and/or Account #)DELETE (Cancel Existing Participation)
I (we) hereby authorize The Select Group (the "Company" to initiate credit entries and if necessary, initiate debit correction or adjustment entries to make (our) account(s) at the financial institution(s) indicated below.
Type of Account*

CheckingSavings
Depository Financial Institution (Name of your bank)*
Branch (City)*
Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ROUTING NUMBER*
ACCOUNT NUMBER*
This authority is to remain in full force and effect until the Company has received written notification from me (or either of us) of its termination in such a time and manner as to afford the Company and the Depository Institution a reasonable opportunity to act on it.
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Agent Office Location*
Signature*

Clear
ATTACH A VOIDED CHECK OR FINANCIAL INSTITUTION VERIFICATION LETTER FOR ACCOUNT VALIDATION

This form is to be retained by the Company as a matter of record. Please retain a copy for your records.
File Upload*

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AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)