Automatic Withdrawal Authorization Form 2017-2018
This Automatic Withdrawal Form is used for authorizing AFTER 3@PLP-Pine Lake Preparatory to withdraw monthly payments directly from your bank account at the time periods specified below. Please complete all three sections.
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SECTION 1: Payments – Please check applicable option
_____ Full Time - 1 Student per Month $280_____ Part Time - 1 Student per Month $185
_____ Full Time - 2 Students per Month $450_____ Part Time - 2 Students per Month $285
_____ Full Time - 3 Students per Month $600_____ Part Time - 3 Students per Month $385
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SECTION 2: Account Authorization for Automatic Withdrawals and Scheduled Payment Dates. Each month will be tuition and any applicable fees that were incurred.
Payment Number / Due DatePayment 1 / Friday, August 11, 2017
Payment 2 / Friday, August 25, 2017
Payment 3 / Friday, September 15, 2017
Payment 4 / Friday, October 20, 2017
Payment 5 / Friday, November 17, 2017
Payment 6 / Friday, December 15, 2017
Payment 7 / Friday, January 19, 2018
Payment 8 / Friday, February 16, 2018
Payment 9 / Friday, March 16, 2018
Payment 10 / Friday, April 20, 2018
Type of account: Checking Savings
Bank Name: ______
Routing # (9 Digits): ______Account # (10 Digits):
Please attach a VOIDED check.
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SECTION 3: Personal Information
Name: ______
Street Address: ______
City: ______State: ______Zip: ______
Phone: ( ______) ______Email: ______
AUTHORIZATION AGREEMENT FOR AUTOMATED WITHDRAWALS:
I hereby authorize and request AFTER3@PLP-Pine Lake Preparatory to make withdrawals in the amount checked above plus the amount of applicable late fees, if any, on a monthly basis by initiating debit entries to my account indicated on the voided check copy provided, and I authorize and request BANK to accept my debit entries initiated by AFTER3@PLP-Pine Lake Preparatory to such account. It is understood that this agreement may be terminated by me at any time by written notification to AFTER3@PLP-Pine Lake Preparatory. Any such notification to AFTER3@PLP-Pine Lake Preparatory shall be effective only with respect to entries initiated by AFTER3@PLP-Pine Lake Preparatory after receipt of such notification and a reasonable opportunity to act on it.
Signature: ______Date: ______