Authorization Agreement for Direct Deposits

This authorization is to remain in full force and effect until Pediatric Associates has received written notification from me (or either of us) of its termination in such time, and in such manner as to afford Pediatric Associates and Financial Institution a reasonable opportunity to act on it.

Vendor Name(Required)

Email(Required)

I (we) hereby authorize PEDIATRIC ASSOCIATES to initiate credit and, if necessary, debit entries and adjustments for any credit entries in error to my (our) Checking Account, at the depository Financial Institution indicated below. I (we) acknowledge that the authority will remain in effect until I (or either of us) have cancelled it in writing, and that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.titled(Required)

I authorize.

I do not authorize.

Financial Institution(Required)

Branch(Required)

Address(Required)

City State / Province / Region ZIP / Postal Code

Routing Number(Required)

Account Number(Required)

Tax ID Number(Required)

Date(Required)

By selecting the "I Accept" button, you're signing this Authorization Agreement for Direct Deposits electronically. You agree your electronic signature is the legal equivalent of your physical signature.(Required)

I Accept.

Font Size: