203 612 2821, 203 595 5333


I/we , hereby authorize Mypayanam, to initiate debit entry to my (our) (select one) account indicated at the depository financial institution named below:

Bank Information

Bank Name: Branch(if applicable):
City, State, ZIP: Total Amount (USD):
Transit/ABA No(“Routing #”): Account #:
Passenger(s) Name: Email: Total no of passenger(s) :

I will support this authorization with scanned copies of my check and a federal ID such as a valid driver's license.
I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. If necessary, credit entries and adjustments for any debit entries in error. Please be aware if you ACH is returned, there will be an additional fee $75/- plus 4.5% merchant fee. By signing below, I acknowledge this signed form is my authorization of this transaction.
SIGNATURE: _________________________________ DATE: _______________