Howell PAL

Automatic Billing Authorization Form

As indicated below, I hereby authorize Howell Township Police Athletic League to initiate a debit on the 20th of each month to either my checking/saving account or to my credit card for payment of the next month’s tuition.  Should the 20th of the month fall on a weekend or holiday the payment will be extracted on the business day prior to the weekend or holiday.  The amount of the monthly debit will be in accordance with the “program and attendance frequency” indicated on the signed Registration Form and/or Change Form(s) that I have submitted and the agreed upon rate.  I understand all other incurred fees will be charged to either my checking/savings account or to my credit card at time of service.  I further authorize Howell Township Police Athletic League to initiate entries to my checking/savings account or to my credit card for any transactions credited/debited in error.  I acknowledge that The Howell Township Police Athletic League is not responsible for providing advanced or subsequent notification of any transaction initiated to my financial account due to a prior billing error.  This authority will remain in effect through the end of the 2010/2011 school year (last scheduled debit is May 20th, 2011 for the June 2011 monthly tuition) or until Howell Township Police Athletic League is notified by me in writing to cancel it in such time to afford Howell Township Police Athletic League and the financial institution a reasonable opportunity to act on it. 

(1) ACH Authorization

     Name of Financial Institution _____________________________________________________

     Address of Financial Institution ____________________________________________________

     Financial Institution Routing # ____________________________________________________

     Checking Account # _____________________   or   Savings Account # ____________________

     Name – PLEASE PRINT _________________________________________________________

     Address – PLEASE PRINT _______________________________________________________

     Signature _____________________________________       Date ________________________

 (2) Credit Card Authorization

    (Circle which card applies)           Visa               Master Card            American Express          Discover

     Name on Credit Card – PLEASE PRINT _____________________________________________

     Billing Address – PLEASE PRINT __________________________________________________

     Credit Card # __________________________________    Expiration Date ______________

      Security Code (Visa, MC & Discover 3 digit code on back; Amex 4 digit code on front) ____________

      Signature _________________________________________     Date ________