Common Contracts
1 similar Ach Debit Authorization Agreement contracts
ACH DEBIT AUTHORIZATION FORMAch Debit Authorization Agreement • January 25th, 2010
AUTHORIZATION AGREEMENT BANK OR FINANCIAL INSTITUTION INFORMATION Name of Bank: Type of Account:□ Checking□ Savings Payment Deducted on:□ 1st of each month□ 15th of each month Bank Address: Routing Number: City, State, Zip: Account Number: Initial Payment:$ Recurring Payment:$ ACCOUNT HOLDER INFORMATION Name on Account: Phone: Address: City, State, Zip: Authorized Signature on Account: Date: ☑ I hereby authorize FuseLodge LTD to process debit entries from my account. This authority will remain in effect until I give reasonable notification (30 days) to terminate this authorization, or until the last specified payment date. I understand the initial payment may include the first and last months payment anda $100 non-refundable membership fee.
