ACH Authorization Form

ACH Authorization Form

Please type all information requested directly into the form below by tabbing to each field and replacing its contents with your own information. Then, print it, sign it, and fax it to 1-413-480-3977. Or email it to
Your Personal or Company Name
as it appears on your check:
Your Personal or Company Street
Address as it appears on your check:
Your Personal or Company City,
State, and Zip Code as they appear on your check:
Bank Name as it appears on your check:
The nine (9) digit Bank Routing Number: /
Account Number: /
Retype Account Number: /
Please write "VOID" on the top of the actual check, copy it, and fax it along with this form.
Please type your mother's maiden name for security purposes:
Print Name (and title if a business) of the authorized signer on account:
Telephone Number of Authorized Signer:
Debit Amount:
Type YES to authorize ACH DEBIT for Deposits and Other Payments:
I hereby authorize LISTYOURSELF.NET, Inc., upon receipt of a facsimile or authenticated e-mail from me, to initiate and process a debit transaction through JPMorgan/Chase Bank and the Automated Clearing House, for payment of deposits and other charges to my account.
This authorization is to remain in full force and effect until LISTYOURSELF.NET, Inc. has received written notification of change.
Attach a voided check to verify the bank account information listed above.
Type YES to authorize ACH CREDIT for Refunds and Other Credits:
I hereby authorize LISTYOURSELF.NET, Inc., to initiate and process credit transactions through JPMorgan/Chase Bank and the Automated Clearing House, for payment of refunds or other credits to my account.
This authorization is to remain in full force and effect until LISTYOURSELF.NET, Inc. has received written notification of change.
LISTYOURSELF.NET, Inc. may initiate an ACH Pre-Note through my financial institution at any time prior to commencement of services.

Bottom of Form

Authorized Signature: ______

Date (MM-DD-YYYY): ______

PRINT, SIGN, AND FAX THIS FORM TO: LISTYOURSELF.NET, Inc. 1-413-480-3977 (fax).
If this form is for a business checking account, we must receive it no later than
7:00pm Central Time, two (2) business days prior to deadline.
If this form is for an individual's checking or savings account, we must receive it no later than
7:00pm Central Time, three (3) business days prior to deadline.
Questions? Call 1-914-217-4475.