Gateway Academy ACH Payment

Bank Draft Form Authorization

Parent's Full Name *

First Name

Last Name

Email*

Please select:*

New Student Enrollment Account Information Change

Student's Name *

First Name

Last Name

Student's Grade:*

Will this bank account be used for another student?

YES NO

Student's Name

First Name

Last Name

Student's Grade

Will this bank account be used for another student?

YES NO

Student's Name

First Name

Last Name

Student's Grade

Will this bank account be used for another student?

YES NO

Student's Name

First Name

Last Name

Student's Grade

Will this bank account be used for another student?

YES NO

Student's Name

First Name

Last Name

Student's Grade

Account Holder's Name (as printed on check)*

First Name

Last Name

Bank Name*

Bank Routing #*

Bank Account #*

Type of Account:*

Checking Savings

This authorizes Gateway Academy to send debit entries (and the appropriate credit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account indicated below and to other accounts I (we) identify in the future (the "account"). This authorizes the financial institution holding the account to post all such entries.

I understand this authorization will be in effect until Gateway Academy receives a written termination notice from myself and has a reasonable opportunity to act on it.

Signature

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Use your mouse or finger to draw your signature above