AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (we) hereby authorize Xxx t State University to initiate debit (take from) and where appropriate credit (add to) my (our) Checking Savings indicated below and the depository named below, hereinafter called Financial Institution, to debit the same to such account. Please assure that your financial institution has automated debit/credit capabilities for the account listed below. In the event that Kent State University deposits funds erroneously into my (our) account, I (we) authorize Kent State University to debit my (our) account for an amount not to exceed the amount of the erroneous deposit. FINANCIAL INSTITUTION CITY STATE TRANSIT/ABA NO. BRANCH BANK PHONE NO. ( ) ACCOUNT NO. This authority is to remain in full force and effect until Kent State University and Financial Institution have received written notification from me (us) of its termination in such time and in such manner as to afford Kent State University and Financial Institution a reasonable opportunity to act on it or upon completion of the 30th monthly payment. NAME(S) ON ABOVE ACCOUNT SSN NUMBER DATE SIGNED X DAYTIME PHONE NO. DATE STUDENT/PARTICIPANT X X (if under 18 years of age) or (if 18 or old er) DATE BURSAR REPRESENTATIVE X
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. Supporters hereby authorize BOULDER STREET MOTO to initiate DEBIT entries to their accounts on a MONTHLY basis in the amount listed on page 1 of this BSM Supporter Agreement for the purpose of Boulder Street Moto Support. If applicable, this agreement will terminate on the 12-month anniversary date of the first draft following application approval, or until Supporters cancel their Boulder Street Moto Membership by providing 30-days written notice.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (We) hereby authorize Village of Sunbury , hereinafter called COMPANY, to initiate debit entries to my (our) account indicated below and the depository named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account for $ Amount of monthly bill . I (We) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (we) hereby authorize The Water Works Board of the City of Auburn, hereinafter called AWWB, to initiate debit entries to my (our) Checking/Saving account indicated below and the Depository named below, hereinafter called Bank, to debit the same to such account.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I hereby authorize White Oak Sanitation to initiate a debit entry to my checking account indicated below at the depository named below to debit the same such account. I am aware that my checking account will be debited any time between the 2nd and through the 5th of the quarter due.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (we) hereby authorize The City of Auburn's Revenue Office, to initiate debit entries to my (our) Checking account indicated below and the Depository named below to debit the same to such account.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. This authorization is for the Patient Responsibility portion of your xxxx. For contracted insurance, the Patient Responsibility portion will be the amount remaining after insurance payment and adjustment.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I hereby authorize the Ada County Sheriff Employees’ Association (ACSEA) to initiate debit entries to my checking/savings account indicated below and the depository named below to debit the same to such account. Please initial your preferred membership.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I(We) hereby authorize Core Performance LLC hereinafter called CORE, to initiate debit entries, and corrections thereto, to my(our) Debits or Charge Card account indicated below and the depository or credit card named below, hereinafter called DEPOSITORY. IMPORTANT NOTE: Buyer on his or her behalf, or as agent or guardian for a client identified above who will use the Training Program services purchased under this agreement (as used herein, in individually and collectively, “buyer”), signing and agreeing to partake in the Training Program, and release Core Performance LLC from liability due to participation. Buyer is urged to have this release agreement reviewed by an attorney before signing. By signing this Agreement, Buyer acknowledges that Buyer has read, understood and agreed with all terms and conditions of this agreement, which includes the E.F.T. Request and Authorization, the Release and Waiver of Liability, and all Additional Terms and Provisions located on the front and reverse side of the Agreement. This agreement constitutes the entire agreement of the parties and no other agreement or understanding exists between Buyer and Core Performance LLC, Core Performance LLC has made no express or implied warranties or misrepresentations other than those expressly set forth in this Agreement to induce Buyer to enter into this Agreement. Any conflict between the original Agreement and any copy of the original Agreement shall be controlled by the original Agreement.
