BROKER AUTO DEPOSIT FORM

Broker Agency Name:

Broker Name:

Tax ID Number:

*
(A separate form is needed for each TIN)

Office Address:

Street Address:	*
City:	*
State / Zip	* / *

I/We hereby authorize SUPERIOR DENTAL CARE, INC. to initiate credit entries to my/our account indicated below at the financial institution named below.

Name on the Account:

Account Number:

* Account Numbers don't match

(Re-Enter) *

Type of Account:

Checking

Savings

Financial Institution Name:

Address:

Street Address:	*
City:	*
State / Zip	* / *

Routing and Transit Number:

This authorization will remain in full force and effect until SUPERIOR DENTAL CARE, INC. has received written notification from the BROKER/BROKER AGENCY of intent to terminate this service in such time and in such manner as to afford SUPERIOR DENTAL CARE, INC. and BANK to act upon it.

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: