Become a Shelter Provider with AAHS!
YES! I want to be a Shelter Provider! Enroll me in your monthly budget plan.
Name
Your answer
Street Address
Your answer
City, State, and Zip Code
Your answer
I authorize my bank to transfer to AAHS each month the amount chosen below:
Your bank will automatically receive notice to charge your account for the designated amount. This will appear on your monthly billing statement from your bank.
Required
Please provide the name and city of your bank.
Your answer
Please provide your bank routing number [ first 9 digits at bottom of check ]
Your answer
Please provide your bank account number [second set of digits at bottom of check]
This may be 10 or 13 digits.
Your answer
My authorization to charge my account at my bank shall be the same as if I had personally signed a check to AAHS. This authorization shall remain in effect until I notify my bank or AAHS in writing that I wish to end this agreement and my bank or AAHS has had reasonable time to act on it, or until my bank or AAHS has sent me ten days written notice that they will end this agreement. A record of each charge will be included in my regular bank statement and will serve as my receipt.
Please type your name. This will serve as your signature.
Your answer
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