AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBITS – Asbury House Child Enrichment Center

Person 1 Information

Title *

Please select your appropriate title.

Name of Person 1 *

First

Last

Email *

Confirm Email

Phone Number of Person 1 *

Mobile Numbers work best.

Yes, I would like to receive text reminders from Asbury House.

Person 2 Information

Title of Person 2

Please select your appropriate title.

Name of Person 2

First

Last

Email of Person 2

Confirm Email

Phone Number of Person 2

Mobile Numbers work best.

Yes, I would like to receive text reminders from Asbury House. (Person2)

Address 1 *

Address 2

City *

State *

Zip *

Amount of Donation *

Other amount to donate:

This is the amount you wish Asbury House to withdraw monthly from the listed source.

Authorization Requirement:

I Do Authorize.

I/we hereby authorize, Asbury House Child Enrichment Center, hereinafter called COMPANY, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) account indicated above and the bank named above, hereinafter called BANK, to debit and/or credit the same to such account. This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it. COMPANY will withdrawal the requested amount of funds from BANK on the 5th of every month beginning the 5th of the month following the date the form was signed.

Bank Name *

Routing Number *

Account Number *

Account Type *

Signature Name *

First

Last

Type you first and last name to show as signature of this form for submission.