SUMMER - AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (Electronic Funds Transfer)
Email address *
Dancer's Last Name *
Dancer's First Name(s) *
I understand and accept the following: *
I understand and accept the following: *
I understand and accept the following: *
I hereby authorize Chase Bank to initiate entries to my Financial Institution:
Debiting Account - Your Financial Institution *
Name on Account *
Routing Number (from check not deposit slip) *
Account Number *
Amount to be debited: *
Effective Date *
MM
/
DD
/
YYYY
Signature of Debiting Customer (Please type your Name as Signature) *
Date of Signature *
MM
/
DD
/
YYYY
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