Auto-payment agreement

Members First and Last Name ( Fill this form to make your payment to be deducted automatically from your Bank account) *

First

Last

Cell Phone

Name as shown on the check ( If Different)

If You are paying for another person or relative. Please fill the name of the bank account holder here.

Routing Number *

Number on the bottom left side, ex Bankof america:- 052001633, CapitalOne: 031176110 WellsFargo: 054001220

Account Number *

Bank Name (ex. Bank Of America, Chase, Capitol One, etc.)

Bank Account Type (select one) *

Checking
Saving
Business

Checkboxes *

I Agree for Dirbyaber Eder to Pay my Invoices using my account information.

1) EDIR Meredaja - Bill.com shows in your account 2)You fill this form only onetime. 3) If you change your account number you may need to refill again.