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Automatic Bank Debit
After this form is complete, you will be emailed a link within 48 hours to complete a Pre-Authorized Debit agreement that will allow us to debit your bank account.
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* Indicates required question
Your name (First & Last)
*
Your answer
Email address
*
Your answer
Please debit my bank account in the amount of:
*
Your answer
In the frequency of:
*
Weekly
Bi-weekly
Monthly
Bi-monthly
Annually
Just this one time
Starting on:
*
MM
/
DD
/
YYYY
Towards:
*
General
Other:
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