Kenosha Symphony Orchestra - Pre-Authorized Check Debit Form

Kenosha Symphony Orchestra
Pre-Authorized Check Debit Form
Please print this form, complete, and mail to:
Kenosha Symphony Association
723 - 58th Street
Kenosha, Wisconsin 53140

Name:___________________________________________________________

Address:_________________________________________________________

City/State/Zip:____________________________________________________

Home Phone:_____________________________________________________

Home Email Address:______________________________________________

Bank Name:______________________________________________________

Bank Routing # (first 9 digits at bottom of check):_______________________

Checking Account #:_______________________________________________

Amount of monthly debit: $______________

PLEASE INITIAL THE TRANSACTION DAY OF YOUR CHOICE:

___ 1st Day of Each Month or ___ 15th Day of Each Month

Please attach a voided check to this application. Your payment will be deducted
from this checking account each month on the day you have chosen.

I hereby authorize a monthly bank draft on the account designated above, until
canceled in writing. The amount of the monthly draft shall be as shown above
and will be changed only with my written approval. I understand that I can
cancel this authorization at any time with ten (10) days written notice. I
understand & authorize all dishonored checks plus a processing fee of $25.00
(or legal limit) with applicable taxes to be electronically debited
from my account.

Signature________________________________________________________

Today's Date:_____________________________________________________

First Draft Date:___/___/___ For office use only:

Total Monthly Draft Amount:_________________ Account #__________________

First Draft Date:___/___/___	For office use only:
Total Monthly Draft Amount:_________________	Account #__________________