Automatic Bank Withdrawal Authorization | 2014 -2015
I/We hereby authorize Western Mennonite School to charge my/our bank account for the purposes designated below. My/Our bank is authorized to handle withdrawals on the 10th of each month or the next banking day as if I/we had personally issued a check. I am/We are all the persons whose signatures are required to sign on the account below. I/We will undertake to promptly notify Western Mennonite School, in writing, of any change in the account information provided in this authorization. Authorization will remain in effect until notification to terminate or limit is given in writing or by email. Personal Information Last Name: Phone Number:
First Name:
Middle Initial:
Email:
Mailing Address: City
State
Zip Code
Bank Information (Attach a voided check -OR- fill in information below) Name:
Account Type:
Checking
Savings
Mailing Address: City Account Number:
Routing Number:
State
Zip Code
Amount: $
Authorized Signatures X Signature of Bank Account Holder
Date:
_____
X Signature of Bank Account Holder
Date:
______
Western Mennonite School
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