ACH Payments | Dar El Salam

Bank Information

I (we) hereby authorize Dar El Slam travel Inc to initiate entries to my (our) checking/savings accounts at the financial institution listed below and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until Dar El Salam Travel is notified by me (us) in writing to cancel it in such time as to afford Dar El Salam travel and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.

Bank Name*

Bank Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Electronic Signature & Date

Electronic signatures are legally binding as covered by the ESIGN act of 2000 and Uniform Electronic Transactions (UETA) in the USA, the Electronic Signatures Directive of 1999 and 1993 in the EU, and various other laws in most jurisdictions around the world.

Name*

First Last

Date*

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Trip Information

Trip Type*

What type of trip is this payment for?

Payment Type*

Is this an initial payment or an installment payment?

Account Information

Amount*

Reference Number

Routing Number*

Account Number*

ACH Authorization Form

Bank Information

Electronic Signature & Date

Personal Information

Trip Information

Account Information