Direct Deposit Enrollment

Full Name *

Address *

Address

City

State/Province

Zip/Postal

Name of Bank *

9-Digit Routing # *

Account Number *

Type of Account *

Checking

Savings

Email *

reCAPTCHA

If you are human, leave this field blank.

check

ACH Direct Deposit Enrollment Form

Full Name:

Address:

Name of Bank:

9-Digit Routing #:

Account Number:

Type of Account:

LowerMyRx Group Code:

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

March 6, 2021 11:03 am EDT

ACH Direct Deposit Enrollment Form Uploaded by Philip Venticinque - [email protected] IP 98.110.110.85