Glass Casa ACH Form

Your Name *

First

Last

Company Name

Your Email *

Company Name

Name of Financial Institution *

Financial Institution Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name on Account

Financial Institution Routing Number *

Checking/Savings Account Number *

Message

Glass Casa ACH Esign Document

Your Name: Your Email:

Name of Financial Institution:

Financial Institution Address:

Name on Account:

Financial Institution Routing Number: Checking/Savings Account Number:

Consent to Store Information:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

February 15, 2021 3:42 pm CDT

Glass Casa ACH Esign Document Uploaded by Randy Bacik - randy@glasscasa.com IP 70.165.31.44, 127.0.0.1, 198.71.243.25, 0.0.0.0

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