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

11