ACH Authorization
Please use this form to set up ACH authorization for monthly payments.
First Name *
Your answer
Last Name *
Your answer
ITS Number
Your answer
Name of Financial Institution *
Your answer
Address of Financial Institution *
Your answer
Checking/Savings Account Number *
Your answer
Routing Number *
Your answer
I agree to pay the invoiced amount in equal installments over the following number of months: *
Your answer
I agree for invoiced amount installment payments to begin in the month of (must be within the next three months): *
Your answer
I agree to the withdrawal date of the monthly installment on/near: *
By typing my name below, I hereby authorize Anjuman-e-Qutbi (Orange County) to initiate regularly scheduled debits to my checking/savings account at the financial institution listed above, beginning in the month I selected above. My account will be debited in equal installments of the invoiced amount indicated on my invoice over the number of months I have selected above on or near the withdrawal date I have selected above. *
Your answer
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