Microsoft Word - Autopay Authorization Agreement.docx

Marco Island Yacht Club Authorization Agreement for Automatic Payment Plan Member’s Name:________________________________________________Membership Number:__________________ The undersigned Member authorizes the Marco Island Yacht Club (hereinafter, the “MIYC”) to electronically debit (and if necessary, electronically credit, to correct erroneous debits) to my (our) Checking or Savings Account at the depository financial institution, named below. Alternatively, I (we) may authorize MIYC to electronically charge my (our) VISA or MasterCard Credit Card named below. I (we) agree that the Automatic Payment transactions that I (we) authorized comply with all applicable law. All Debits will be made between the 15 th and the 17 th of each month for the prior month’s full statement balance.

[ ] CHECKING and SAVING ACCOUNTS – PLEASE ATTACH A VOIDED CHECK FOR THIS ACCOUNT. US Banks Only.

Depository (Bank) Name:______________________________________________________________________________ Branch:____________________________________________________________________________________________ City:______________________________________________________State/Zip:________________________________ Name on Bank Account:______________________________________________________________________________ Bank Routing Number:_____________________________ Bank Account Number:___________________________ —————————————————————————————————————————————— [ ] VISA – DO NOT COMPLETE IF YOU ARE SUBMITTING A CHECKING OR SAVINGS ACCOUNT [ ] MasterCard Name on Credit Card (exactly as it appears on card):________________________________________________________ Credit Card Billing Address:____________________________________________________________________________ Credit Card Number______________________________________________ Expiration Date:______________________ Billing Zip Code:_________________________________________________ Security Code:_______________________ Please use the above account for my (our) [ ] Monthly Statement [ ] Annual Dues (Check all that apply). Members who would like to pay their annual dues from a different Checking or Savings account (separate from the monthly billing of all other charges) may do so by completing this section. US Banks only. [ ] Please debit the following account for my (our) annual dues. Please attach a voided check for this account. Depository (Bank) Name:______________________________________________________________________________ Branch:____________________________________________________________________________________________ City:______________________________________________________State/Zip:________________________________ Name on Bank Account:______________________________________________________________________________ Bank Routing Number:_____________________________ Bank Account Number:___________________________ This authorization shall remain in full force and effect until the MIYC has received written notification from the undersigned of termination in such time and in such manner to afford the MIYC and the Depository time to make any necessary changes to their records, which shall, in no event, be less than thirty (30) days. _______________________________________________ _______________________________________________ Signature Signature _______________________________________________ _______________________________________________ Print Name Date Print Name Date

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