I (we) hereby authorize Portland Executives Association hereinafter called COMPANY, to initiate DEBIT entries to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account on a recurring basis. I (we) acknowledge that the origination of ACH transactions from my (our) account must comply with the provisions of U.S. law.
Name on Account
Bank Name
Routing Number
Account Number
Bank City, State
Type of Account —Please choose an option—Personal CheckingBusiness CheckingPersonal SavingsBusiness Savings
Phone Number of Account Holder
This authority is to remain in full force and effect until COMPANY has received advance written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it of at least 21 days.
Consent I agree to automatic withdraw payments
By agreeing to the release of the given information, the agreeing party is consenting to allow Company to automatically withdraw payments monthly via ACH from the designated bank account.