Bank Debit Authorization

Terms of Use: By submitting this form, I agree to allow Green Marimba Technologies LLC to debit my bank account for pre-approved and recurring invoices.

Bank Authorization Form

Company Name*
First Name*
Last Name*
Bank Name*
Name on Account*

Name of the account as it appears on the bank statement.
Address*

Address of the account as it appears on the bank statement.
City*

City of the account as it appears on the bank statement.
State*

State of the account as it appears on the bank statement.
Zip Code*

Zip code of the account as it appears on the bank statement.
Routing Number*

9-digit ABA routing number.
Account Number*
Your Name*
Title*

Your title in the organization.
Phone*
Email*

Email addresses to receive billing notifications.
Agreement*
- I have read and understood the Terms of Use Agreement shown above.
E-Signature*

To e-sign this authorization, type your name in this format: /first-name last-name/