AUTHORIZATION AGREEMENT

ACH/AFT PREAUTHORIZED PAYMENTS (DEBITS) 

*Please return:  Completed Form and Voided Check to WBFJ: 

Cindy Davis, WBFJ-FM

1249 Trade Street

Winston-Salem, NC  27101 

AMOUNT  $________________

SELECT DRAFT DATE CHOICE: 

1st of Month   _____ 

15th of Month  _____   

I hereby authorize Triad Family Network (WBFJ-FM) to initiate debit entries or such adjusting entries, either debit or credit which are necessary for corrections, to my Checking ____  Savings _____ account indicated below and the financial institution named below to credit (or debit) the same to such account. 

 

 

FINANCIAL INSTITUTION NAME                                                      CITY                                        STATE

 

 

BANK TRANSIT/ROUTING NUMBER                                                BANK ACCOUNT NUMBER  

 

I understand that this authorization will be in effect until I notify my financial institution, in writing, that I no longer desire this service, allowing it reasonable time to act on my notification.  I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account.

 I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged.  If an erroneous debit entry is charged against my account, I have the right to have the amount of the entry credited to my account by my financial institution.  I agree to give my financial institution a written notice identifying the entry, stating that it is in error, and requesting credit back to my account.  I will provide this written notice within 15 calendar days following the date on which I was sent a statement of my account or a written notice of such entry, or 45 days after posting, whichever occurs first.  

 

NAME (Please Print)                                                                                     SOCIAL SECURITY NUMBER

  

 

SIGNATURE                                                                                                DATE  

Call Cindy Davis @ 336-721-1560 with any questions