Electronic Funds Transfer (EFT) & Electronic Remittance …

www.triwest.com

Authorization Agreement This form authorizes PGBA, LLC to administer any payment to you as an Electronic Funds Transfer (EFT). Please complete all fields on page 1 and 2 of this form. Form Completion Guidelines and Terms and Conditions can be found on pages 2 and 3. Please retain a copy of the completed EFT Authorization Agreement for your records.

  Agreement, Electronic, Authorization, Fund, Transfer, Remittance, Electronic funds transfer, Authorization agreement, Eft authorization agreement, Amp electronic remittance