Auto Pay Authorization I hereby authorize Western Mennonite School to charge my bank account monthly for the purposes designated below. My bank is authorized to handle withdrawals on the 10th of each month or the next banking day as if I had personally issued a check. I 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:
First Name:
Phone Number:
Email:
Middle Initial:
Mailing Address: City
State
Zip Code
Bank Information (Attach a voided check –OR– fill in information below) Account Type:
Name:
☐ Checking ☐ Savings
Bank Address: City Routing Number:
☐ Tuition/Fee Amount: $(payment may vary)
State
Zip code
Account Number:
☐ Monthly Donation Amount: $
Authorized Signatures X
Date: Signature of Bank Account Holder
X
Date: Signature of Bank Account Holder