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)

Full Name:

Former Employer (school district):

My Mailing Address:

Phone Number:

City, State  Zip Code:

Email Address:

Bank Account Information:

Bank Name:

Name on Account:

Bank Routing Number:

(9 digits)

Account Number:

Type of Account:

Thank you. 

Your form has been submitted.  Your account will be debited as you indicated.