THE NEW 49ERS

27 Davis Road P.O. Box 47 Happy Camp, CA 96039

(530) 493-2012 Fax: (530) 493-2095

www.goldgold.com

 

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER


 

I (we) hereby authorize The New 49ers to initiate electronic debit and credit entries to my (our) checking/credit card account identified below. This authority pertains to monthly or annual membership payments to The New 49ers.
 

I (we) authorize the financial institution named below to honor the debit or credit card entries initiated by the New 49ers and post such entries to my (our) account.
 

I (we) understand that this authorization allows the New 49ers to deduct from my (our) checking account or charge our credit card amounts due to the New 49ers, and that they agree to notify me (us) of any change in the debit amount prior to the posting of entries to my (our) account.
 

I (we) understand that both the financial institution and the New 49ers reserve the right to terminate this payment plan and/or my participation therein at any time. I, too, can elect to discontinue my participation in this plan by providing written notice to the New 49ers within a sufficient amount of time to afford the New 49ers and the named financial institution to act on it prior to the next payment date.


 

ACH Bank Debit

Customer Name:


 

Name of the Financial Institution


 

Branch Address of Financial Institution:


 

Name(s) on Account:


 

Routing/ABA# :


 

Checking Account #


 


 


 


 

Credit Card

Customer Name:


 

Last four numbers of Credit Card:


 

Credit Card Company:


 

Name on Credit Card:


 

Credit Card Type (Visa, Master Card, Discover):


 

Expiration Date:


 


 

Signed: ________________________________________________



 

Date: ___________________________________________________


 

To ensure accuracy, if deducting from a bank account, please attach a sample check marked VOID from the bank account you have selected above. Customers of credit unions should verify their account number through their local office as many credit unions use a different account number than the one reflected on the check.