Missouri Chiropractic Legal Defense Fund
Authorization Agreement for Direct Debits from Banking or Credit Card Accounts 15320 Manchester Rd. * Ellisville, MO 63011 * (636) 227-4378 * Fax: (636) 227-4684
Name:__________________________________________________________________________________________________________ Address:________________________________________________________________________________________________________ City: __________________________ State: _________ Zip: ______________ Email: ________________________________________ Contact Number:________________________ Fax: ___________________________________________________________________
Bank Account Information
______________________________________________________ Bank Name and Branch
______________________________________________________ Account Number
______________________________________________________ City, State, Zip
______________________________________________________ Bank Transit/ABA Number
ATTACH VOIDED CHECK HERE Credit Card Information
MasterCard, Visa or Discover (please circle one) Card Number: __________ - __________ - __________ - __________
Expiration Date: _______________________________________
3 Digit Security Code: __________ (Last 3 numbers in signature area on back of card) Name as it appears on credit card: _________________________________________________________________________
Billing Address: ____________________________________ ___________________________________ Address
City/State/Zip Amount: $100________ $200 ________ $500 ________ Other $ ________
As a convenience to me, I hereby request and authorize Missouri Chiropractic Legal Defense Fund to pay or charge my checking account or credit card via electronic debits, checks or drafts, drawn on my account indicated above by and payable to the order of the Missouri Chiropractic Legal Defense Fund, provided there is sufficient collected funds in said account to pay upon presentation. I agree that the Missouri Chiropractic Legal Defense Fund rights in respect to each such draw shall be the same as if it were a check drawn on you and personally signed by me. Furthermore, if this option is selected, I request and authorize the Missouri Chiropractic Legal Defense Fund to charge my credit card account, providing there is sufficient availability on my credit card account to pay upon presentation. This authorization is to remain in full force, on a monthly basis, until the Missouri Chiropractic Legal Defense Fund has received a written notification from me of its termination in such a manner as to afford the MISSOURI CHIROPRACTIC LEGAL DEFENSE FUND, the BANK, and/or the CREDIT CARD COMPANY reasonable opportunity to act on it.
Account Holder Signature: ___________________________________________________________ Date: ______________
Te Missouri Chiropractor July 2014
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