Page 23 - HSP-Assure Test Booklet FDA Auth Booklet - FINAL 9_23_2020

ACH Authorization Form

• You r accoun t will be debi t ed aut omatically when y our p ayment s
i
due
• Compl et e aut hori zati on orm and att ach a v oi ded check
f
• Fax orm o +1 910 399 7381
t
f
Company Name: ______________________________________________________________

Address: ______________________________________________________________

Suite / Building #: ______________________________________________________________

City: _________________________ State: _______________ Zip: ___________

Financial Institution: ______________________________________________________________

Address: ______________________________________________________________

Suite / Building #: ______________________________________________________________

City: _________________________ State: _______________ Zip: ___________

Bank Routing #: _______________________________

Bank Account #: _______________________________

I hereby authorize Hensler Surgical to debit my checking or savings account to collect
my payments:

Signature: ____________________________________________________________

Name: ____________________________________________________________

Title: ____________________________________________________________

Date: ____________________________________________________________