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 Applicable Amount 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
