© 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)

On the 1st day of each month

On the 15th day of each month

Full Name:
Former Employer (school district):
My Mailing Address:
Phone Number:
City, State  Zip Code:
Email Address:

Please send me a notification email when my account is debited.

Bank Account Information:
Bank Name:
Name on Account:
Bank Routing Number:
(9 digits)
Account Number:
Type of Account:
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