eCheck Payment eCheck Electronic Payment Name(Required)Phone(Required)Email(Required) Street Address(Required)City(Required)State(Required)Zip Code(Required)Banking Information Name of Bank Account Owner(Required)Name of Banking Institution(Required)Type of Bank Account(Required)Checking AccountSavings AccountBank Routing Number(Required)Bank Account Number(Required)Check # If ApplicableAmount Due(Required)ACH (eCheck) Debit Authorization(Required) ConsentI authorize the Washington County Historical Society to electronically debit the bank account of which I am an authorized signor as identified above. I represent and warrant that I am authorized to execute this payment authorization. Signature(Required)Type Name Of Authorized Signer For Signature. Date(Required) MM slash DD slash YYYY Δ
