Quarterly Dues Auto-Payment Authorization Form
Quarterly Dues Auto-Payment Authorization Form
Please complete this form to authorize automatic payment for quarterly dues.
Member Information
Name
Address
Phone Number
Payment Information
Bank Name
Bank Routing Number
Account Number
Payment Amount
Billing Cycle
First Payment Date
Subsequent Payment Schedule
Authorization
I authorize [Your Company Name] to initiate automatic electronic deductions from the account indicated above for quarterly membership dues. I understand that this authorization will remain in effect until I cancel it in writing or until the conclusion of my membership, whichever occurs first.
Name:
Date:
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