Page 18 - Hensler Surgical - Biosciences COVID Rapid Testing Proposal - Facility_Clinic_Hospital - 5_6_2020

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ACH Authorization Form

• Your account will be debited automatically when your payment is due
• Complete authorization form and attach a voided check
• Fax form to +1 480 207-1863

Company Name: ______________________________________________________________

Address: ______________________________________________________________

Suite / Building #: ______________________________________________________________

City: _________________________ State: _______________ Zip: ___________

Financial Institution: ______________________________________________________________

Address: ______________________________________________________________

Suite / Building #: ______________________________________________________________

City: _________________________ State: _______________ Zip: ___________

Bank Routing #: _______________________________

Bank Account #: _______________________________

I hereby authorize BioLab Sciences to debit my checking or savings account to collect my
payments:

Signature: ____________________________________________________________

Name: ____________________________________________________________

Title: ____________________________________________________________

Date: ____________________________________________________________