ACH Authorization Form

Name

This field is for validation purposes and should be left unchanged.

Sensitive data provided in this form, such as bank account information, is stored using double-key encryption.

Name of person submitting form(Required)

First Last

Email(Required)

Bank Name(Required)

Name on Account(Required)

Type of Account(Required)

Checking

Savings

9-Digit Bank Routing Number(Required)

Account Number(Required)

ACH Authorization Signature(Required)

By signing this form I authorize Hill Laboratories to automatically debit this bank account in accordance with the sales contract signed for each order.

Signed by on 06/10/2026.

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Date