AAOPM - eCheck Registration

1. Customer Information

First Name *

Last Name *

Medical Title

Email *

Telephone *

Practice Owner?

State License #

Account Rep (if any)

2. eCheck (ACH) Details

CONSUMER AUTHORIZATION FOR DIRECT DEPOSIT VIA ACH
I (we) hereby authorize AMERICAN ACADEMY OF PROCEDURAL MEDICINE, INC to electronically debit my account as follows at the depository financial institution named below. I (we) agree that ACH transactions that I (we) authorize comply with all applicable law.

Account Type *

Bank (Institution) Name *

Routing Number *

Account Number *

Name on Account *

Amount to be Charged *

Date

Email for Confirmation *

I (we) understand that this authorization will remain in full force and effect until I (we) notify AMERICAN ACADEMY OF PROCEDURAL MEDICINE, INC. in writing that I (we) wish to revoke this authorization.

American Academy of Procedural Medicine, Inc.
2720 East Oakland Park Blvd, #102
Fort Lauderdale, FL 33306
(954) 525-4273

Your Full Name (Authorization) *

eSignature (Type Full Name) *

3. Billing Address

Address *

Address 2

City *

Country *

State *

Zip Code *

I agree to the Terms & Conditions

eCheck Payment