ACH Payment Request

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Vendor Name

Remittance Email

Financial Institution Information

Institution Name

Institution Address

Address Line 1

Address Line 2

City

State

Zip Code

Type of Account

Routing Number

Please upload a copy of voided check

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I hereby give my authorization for Forgen, LLC, and subsidiaries to electronically transfer payment to the account indicated above.

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Signature (typing your name constitutes a signature)

Date

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