Pre-Authorized Check Debit Form
Please print this form, complete, and mail to:
Kenosha Symphony Association
723 - 58th Street
Kenosha, Wisconsin 53140
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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:_____________________________________________________
For office use only: Account #__________________
First Draft Date:___/___/___
Total Monthly Draft Amount:_________________