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ACH Authorization Agreement Form

 

 

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (ACH DEBITS)

 

I (we) herby authorize BRETHREN CHRISTIAN JUNIOR AND SENIOR HIGH SCHOOL, INC., hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account/Savings Account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account.  I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Please complete the form below. Required fields marked *

Depository (Bank Information) 

State*
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Please attach a .jpg image of a voided check so that we can verify the account number and routing number.
If you do not attach an image of a voided check, you must bring in a voided check into the BC Business Office to be included with your form.
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or drag it here.

This authorization 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 DEPOSITORY a reasonable opportunity to act on it.

Note: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Electronic Signature

This form declares your intention to pay your Tuition and Fees at Brethren Christian School by reocurring direct withdrawls. By submitting this form, you are verifying that you understand, and agree to the terms and conditions detailed herein. 

Note: Your computer IP address, time and date will be recorded when you click "Submit," authenticating your action and consent.

Do you verify that all the information you provided on this form is correct and accurate to the best of your knowledge, and that by typing your name below you are signing this document?*
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Confirmation Email