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Personal and
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First Name*:
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Last Name*:
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Company Name:
E-mail*:
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Phone:
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Bank
Information:
Bank Name:
Bank Account Number:
Bank Routing Number:
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Personal Account
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Checking Account
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Details:
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I hereby authorize Offix Solutions LLC to use the above bank account for payments using this form. I agree that I will pay for this service and indemnify and hold Offix Solutions LLC harmless against any liability pursuant to this authorization.
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