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Electronic Funds Transfer
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EPHRATA RECREATION CENTER
Authorization For
Membership Direct Charge
Electronic Funds Transfer (EFT)
THIS AGREEMENT is made this _________ day of ______________
I/we authorize the Ephrata Recreation Center to initiate debit entries from my/our account at the bank or financial institution named below, and if necessary, to initiate adjustments for any entries done in error. This authorization shall remain in effect a minimum of eleven (11) months, starting __________ 15th, 200____.
Prices herein stated are subject to change with written notice forty-five (45) days prior t anniversary date of this agreement.
This agreement shall be automatically renewed from year to year subject to price adjustment as aforementioned unless either party notifies the other by written statement to the contrary at least thirty (30) days prior to the end of one year. There after this agreement may be terminated by either party notifying the other by written statement thirty (30) days in advance of the termination date.
I/we understand that I/we are responsible for any debit entries not completed due to insufficient finds or closed accounts.
The Ephrata Recreation Center reserves the right to terminate a membership if debit entry or other payment is not received within ten (10) days of the due date as specified above.
THE MONTHLY DEBIT AMOUNT SHALL BE $____________
Debit entries will be made on or about the 15th of each month.
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Member Name: _____________________ |
SSN#: ____________________ |
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Signature: _____________________ |
Date: ____________________ |
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Member Name: _____________________ |
SSN#: ____________________ |
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Signature: _____________________ |
Date: ____________________ |
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Bank Name: _________________________________ |
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Branch: _________________________________ |
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Transit #: _________________________________ |
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Account #: _________________________________ |
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Please attach a VOIDED check in the area below
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