AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBITS – Asbury House Child Enrichment Center

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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:

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indicated below and the depository named below, hereinafter called DEPOSITORY, to debit and/or credit the same to such account.

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ACCOUNT HOLDER INFORMATION (Primary)

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ACCOUNT HOLDER INFORMATION (Secondary)

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