Request your ACH Debit Authorization below:

Site ID (required)

Your Email (required)

Merchant Name (required)

Bank Routing # (required)

Bank Account # (required)

Debit Amount (required)

Name (required)

Contact # (required)

Please upload an image of a voided check in jpg, jpeg, png, gif format. 10MB size limit. (required)

I (we) hereby authorize Debisys, Inc. dba Emida, hereinafter called COMPANY, to initiate debit entries into my (our) business checking account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of the ACH transactions to my (our) account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. NOTE: WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. (required)
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