Automatic Withdrawal Authorization Form
The completion of this form give Emmaus Biblical Seminary authorization to initiate debt entries to my (our) bank account indicated below and the financial institution named below, to debit the ame to such account. I understand that this authority will remain in effect until I provide reasonable notification to temrinate the authorization.
Name on the Account
Bank and Account Information
Amount to debit monthly
Please debit my account monthly on the:
This notification to draft your account every month will remain in effect until we have received notification from you of its termination, and EBS has had the responsibility to act on it. Your monthly bank statement will adequately describe this draft when it occurs. We will mail a year-end receipt for tax purposes.
Please scan and email a voided check to
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This form was created inside of Emmaus Biblical Seminary of Haiti.
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