AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (we) hereby authorize Kent State University to initiate a debit (take from) and where appropriate credit (add to) my (our) Checking Savings indicated below and the depository named below, hereinafter called Financial Institution, to debit or credit the same to such account. Please assure that your financial institution has automated debit/credit capabilities for the account listed below. In the event that Kent State University deposits funds erroneously into my (our) account, I (we) authorize Kent State University to debit my (our) account for an amount not to exceed the amount of the erroneous deposit. FINANCIAL INSTITUTION BRANCH CITY BANK PHONE NO. TRANSIT/ABA NO ACCOUNT NO. This authority is to remain in full force and effect until Kent State University and Financial Institution have received written notification from me (us) of its termination in such time and in such manner as to afford Kent State University and Financial Institution a reasonable opportunity to act on it or upon completion of the 24th monthly payment. NAME(S) ON ABOVE ACCOUNT SSN NUMBER DATE SIGNED X DAYTIME PHONE NO. DATE STUDENT/PARTICIPANT X X (if under 18 years of age) (if 18 or older) DATE BURSAR REPRESENTATIVE X CONTINUED ON PAGE 2 KENT STATE UNIVERSITY KENT PLUS PROGRAM AGREEMENT ROOM AND BOARD PAYMENT PROGRAM FOR THE ACADEMIC YEARS 2014-2017
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. Supporters hereby authorize BOULDER STREET MOTO to initiate DEBIT entries to their accounts on a MONTHLY basis in the amount listed on page 1 of this BSM Supporter Agreement for the purpose of Boulder Street Moto Support. If applicable, this agreement will terminate on the 12-month anniversary date of the first draft following application approval, or until Supporters cancel their Boulder Street Moto Membership by providing 30-days written notice.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. This authorization is for the Patient Responsibility portion of your bill. For contracted insurance, the Patient Responsibility portion will be the amount remaining after insurance payment and adjustment. Patient Name: Card Holder Name: Type of account (circle one) Master Card Visa Health Savings Expiration Date Last 4 digits of card • I authorize BHS, Inc. to keep my signature on file and to charge the credit card or health savings account identified above for the balance of charges not paid by my insurance, including copayments. • I assign my insurance benefits to BHS, Inc. • I understand I should receive an Explanation of Benefits from my insurance company showing my Patient Responsibility. • I understand that when I receive my statement from BHS, Inc. showing my patient responsibility, I must contact the office immediately to use a different form of payment and not use this authorization form. Patient Signature: Date:
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (We) hereby authorize City of Sunbury , hereinafter called COMPANY, to initiate debit entries to my (our) account indicated below and the depository named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account for $ Amount of monthly bill . I (We) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. Financial Institution Name Transit/ABA# Account# Type of account: Checking Savings Start date Ending date Sewer Account # This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. Printed name Printed name Signature Signature Date
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I(We) hereby authorize Core Performance LLC hereinafter called CORE, to initiate debit entries, and corrections thereto, to my(our) Debits or Charge Card account indicated below and the depository or credit card named below, hereinafter called DEPOSITORY. CARD TYPE: CREDIT CARD EXPIRATIONDATE: ACCOUNT NO. (CC # or Bank Acct #): 3 DIG SECURITY CODE: NAME AS IT APPEARS ON CARD: BILLING ADDRESS (IF DIFFERENT FROM HOME): This authority is to remain in full force and effect until CORE and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford CORE and DEPOSITORY a reasonable opportunity to act on it, or until all payments due under the contract have been made. IMPORTANT NOTE: Buyer on his or her behalf, or as agent or guardian for a client identified above who will use the Training Program services purchased under this agreement (as used herein, in individually and collectively, “buyer”), signing and agreeing to partake in the Training Program, and release Core Performance LLC from liability due to participation. Buyer is urged to have this release agreement reviewed by an attorney before signing. By signing this Agreement, Buyer acknowledges that Buyer has read, understood and agreed with all terms and conditions of this agreement, which includes the E.F.T. Request and Authorization, the Release and Waiver of Liability, and all Additional Terms and Provisions located on the front and reverse side of the Agreement. This agreement constitutes the entire agreement of the parties and no other agreement or understanding exists between Buyer and Core Performance LLC, Core Performance LLC has made no express or implied warranties or misrepresentations other than those expressly set forth in this Agreement to induce Buyer to enter into this Agreement. Any conflict between the original Agreement and any copy of the original Agreement shall be controlled by the original Agreement.
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I hereby authorize White Oak Sanitation to initiate a debit entry to my checking account indicated below at the depository named below to debit the same such account. I am aware that my checking account will be debited any time between the 2nd and through the 5th of the quarter due. Depository Name Branch City State Zip Routing Number Account Name Account Number This authorization is to remain in full effect until White Oak Sanitation has received written notification from me of its termination in such time and in such a manner to afford reasonable time to act upon it. Customer Signature White Oak Account # Date
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I (we) hereby authorize The City of Auburn's Revenue Office, to initiate debit entries to my (our) Checking account indicated below and the Depository named below to debit the same to such account. NAME: BRANCH _ Transit/ ABA No: Bank Account Number: City State: Zip
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS. I hereby authorize the Ada County Sheriff Employees’ Association (ACSEA) to initiate debit entries to my checking/savings account indicated below and the depository named below to debit the same to such account. Please initial your preferred membership. General ACSEA Membership: Fifteen dollars ($15.00) will be debited from my checking account or savings account on the first paycheck of each month, and will continue monthly thereafter. ACSEA Membership Plus (Legal Defense): Twenty-five dollars ($25.00) will be debited from my checking account or savings account on the first paycheck of each month, and will continue monthly thereafter. Depository Name: Branch: City, State, Zip: Account Number: Transit Routing Number: This authority is to remain in full force until the ACSEA has received written notification from me of its termination in such time and in such manner as to afford the ACSEA a reasonable opportunity to act on it. Current ACSO Employees will be eligible to use ACSEA Equipment (Trailers, Golf Cart, etc…) after three months of continued membership. New ACSO Employees who join will be eligible to use ACSEA Equipment immediately. Printed Name: Date: Ada # Signed:
