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
Former Employer (school district):
My Mailing Address:
City, State Zip Code:
Please send me a notification email when my account is debited.