MKA Direct Bank Transfer

Client Banking Account Information & Authorization Form

Please provide the following information for your company’s bank account that will be charged via our direct bank debit service, per the terms of the contract.

Company Name:                                           

Official Name On Bank Account:            

Bank Account Number:                              

Bank Routing Number:                              

Phone Number On File with Bank:        

I,   , authorize Mark Kamin & Associates, Inc. to debit the bank account provided above for the amounts due on the dates stated in the terms of this contract.

Date of Signature: