Association Healthcare Management,Inc

dba AWIS
(Fax) 1.866.837.4556
Direct Deposit Authorization Form for Commissions
Representative ID Number:
Representatives Name:
Bank Name:
Name of the Person / Entity on the Account:
Bank ABA (Routing) Number:
Account Number:
Check One:
Checking Savings
Check Commission to be direct deposited:
Initial Commission Residual Commission
Signature: Date: ________________
Please attach a copy of your void check.
*Authorization forms submitted without a copy or a voided check will not be honored.
Attach Voided Check Here
AWIS_DirectDeposit_Form VER:03172011