IPSSA Payment Information - E-Check

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* 1. Company Name

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* 2. Member # (Optional but helpful if you enter)

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* 3. Bank Name

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* 4. Routing # (Always 9 Digits)

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* 5. Account #

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* 6. Billing Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number