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ACH Debit Authorization

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Name

Invoice Number

Amount

Account Type

Bank Name

City, State, Zip

Routing Number

Account Number

Payment Authorization Date

I (we) wish for this transaction to take place starting on the Payment Authorization Date listed above and to recur:

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Digital Signature (type your full name here to digitally sign this authorization)

This form must be received ten (10) days before your first automatically scheduled payment. Please note that you may enroll or cancel enrollment at any time as outlined on this form.

O'Riordan Migani Architects

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