© 2019 Gentry Financial Group, LLC. All rights reserved.

Gentry Financial Group, LLC

4297 Kinsey Drive

Tyler, Texas  75703

903-939-8133     903-939-2534 (fax)

www.gentryfinancialgroup.com

Automatic Bank Debit (ACH) Authorization Form

I authorize Gentry Financial Group to debit my bank account for my dental and/or vision insurance premiums as follows:  (check your preference)

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