AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (Electronic Funds Transfer)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Fairy Tale Ballet - $75/session

Email *

Dancer's Last Name *

Dancer's First Name(s) *

I understand and accept the following: *

Allegro Dance Studio has permission to deduct $75 from my specified account. Deduction will begin two weeks before your class starts.

I understand and accept the following: *

I understand that a $20.00 NSF will be charged if adequate funds are not available. If this happens, you will be contacted by email. Allegro Dance Studio will not make a second attempt via EFT to collect funds. Account must be made current by paying with check or cash and will include the $20.00 Fee.

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: *

Signature of Debiting Customer (Please type your Name as Signature) *

Date of Signature *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms