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ACH AUTHORIZATION
Fill this online form and sign with an electronic signature
------------------------------------------------------------------------
ISHA TRAVEL INC.
(company)
101 Pecan Valley Dr., Irving, TX 75063
Phone
469-524-8554 / 773-524-0043
E mail:
info@isha-travel.com
Web:
http://www.isha-travel.com
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AUTHORIZATION AGREEMENT FOR AUTOMATIC WITHDRAWALS
(ACH DEBITS)
*
Indicates required field
I (We) hereby authorize Isha Travel Inc. (hereinafter called "Company") to initiate debit entries and to initiate, If necessary, credit entries and adjustments for any debit entries posted in error, to my (our) X checking account (Select one) indicated below. Additionally, I (We) authorize the Financial Institution named below to accept debit and/or credit entries initiated by BB&T, ABA # 111017694 to same account.
*
First
Last
name of bank account holder
for the payment of travel/tour & miscellaneous services of myself and/or family members:
Passenger names
*
list all passenger names separated by commas
Bank Name
*
credit card number
Bank Account #
*
Bank Routing #
*
ABA # Bank Routing Number
in the amount of: (USD)
*
total charge amount
Account Holder Address:
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
ID/Drivers License Copy
*
Max file size: 20MB
Upload copy of State ID/Drivers License of Account Holder
Void Check Copy
*
Max file size: 20MB
Upload copy of void bank check
Signed (Bank Account Holder Name):
*
Date:
*
Submit
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