E-Check APPLICATION FORM
All bold fields are required. Fields marked with * must be entered exactly as shown on your bank statement. Please note that e-check requests can only be accepted from U.S. citizens.
Trading Account Number:	(8 digits)	Use this sample check image as a guide for finding the location of your ABA / routing number and account number. The location of these numbers can vary between banks.
*Name:
*Address Line 1:
*Address Line 2:
*City:
*State:	Choose... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Americas Armed Forces Afr/Can/Eur/MEast Armed Forces Pacific
*Zip:
Country:	USA	ABA / Routing Number:	(9 digits - see above in green)
Primary Phone:		Checking Account:	(see above in blue)
Secondary Phone:		Check Number:	(see above in orange)
Email Address:		Amount: $	(in US Dollars)
By submitting the e-check Application Form, I authorize the First Capitol Group to initiate debit and credit entries, as the case may be, to my Account. I further acknowledge that any transactions made using the Service must comply with US law. This authorization shall remain in effect until the First Capitol Group has received notice and had a reasonable opportunity to act upon such notice.
Please fill in all required fields.