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.
Personal Information
Name on the Account
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip code
Your answer
Email
Your answer
Bank and Account Information
Bank Name
Your answer
Account Number
Your answer
Routing Number
Your answer
Amount to debit monthly
Your answer
Account type
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.
Signature
Your answer
Please scan and email a voided check to finances@ebshaiti.org
Submit
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