ACH Authorization Form

ACH Authorization Form
Founding Sustainer Donor Information
Name: *
SSN: *
I hereby authorize the Florida Public Relations Education Foundation Inc.
To initiate: *
debits/drafts and credits/payments
To my: *
checking accountsavings account
On: *
The 1st Wednesday of the month, orThe 3rd Wednesday of the month
*
I understand that, if necessary, an adjusting debit or credit entry may be made to correct an error.
I also authorize the financial institution named below to credit and/or debit my account for the correcting entries. I duly certify that I am an authorized signer of said account and have the right to enter into this agreement.
ACCOUNT INFORMATION
NAME OF BANK: *
CITY / STATE: *
BANK ROUTING NUMBER: *
ACCOUNT NAME: *
ACCOUNT NUMBER: *
*
I understand this authority will remain in full force and effect until such time as the Florida Public Relations Education Foundation Inc. has received written notification from me that the draft authorization has been revoked. It is further provided that written notification of termination, by either party, shall be provided in such a time and manner as to afford either party reasonable opportunity to act on it.
Signature of Account Owner *
Date *
Please attach a voided check.
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