ACH Debit Form

This form provides a permanent authorization for GSNorcal to initiate product ACH transfers from your troop bank account.

As an authorized signer on the financial institution account identified below, I authorize Girl Scouts of Northern California (GSNorcal) to initiate electronic ACH (Automated Clearing House) transfers to debit or credit the account identified below for financial transactions relating to Product Programs.

I also authorize GSNorcal to repeat any debit that fails for any reason, and understand the troop will be responsible for non-sufficient funds bank fees. This authorization remains in effect for as long as the troop is active and the account remains open.

Troop Information

Service Unit Name/Number *

Troop Number: *

Troop Leader Name: *

Primary Phone: *

Alternate Phone:

Home Address (Street, City, State, Zip): *

Email Address *

Confirm Email: *

Troop Contact Name:

Phone:

Troop Bank Information

Bank Name *

Which Bank? *

Bank Routing Number *

Bank Account number: *

Type of Account: *

Checking

Saving

Signature and Acceptance

Date: * +

Electronic Signature By typing my name on this form, I am entering my "electronic signature" (as defined in The California Uniform Electronic Transactions Act 1633.1 - 1633.17) and certifying that I have read, fully understand and accept all terms of this agreement.

*Name: *