AUTO DEPOSIT PROGRAM

Participating Dentist Name:

Tax ID Number:

*
(A separate form is needed for each TIN)

Office Location:

Name on the Account:

Account Number:

* Account Numbers don't match

(Re-Enter) *

Type of Account:

Checking

Savings

Financial Instituition Name:

Address:

Routing and Transit Number:

Name of Authorized Person:

Fax Number:

Email Address:

Please use our Document Upload to securely send a copy of a voided check (required).

By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.

Initials: