Bank Draft Authorization

*Social Security:	RequiredInvalid format.
*Email:	Required.Invalid format.
*First name & Middle name:	Required
*Last name:	Required.
*Address:	Required.
*City:	Required.
*State:	Required.
*County:	Required.
*Zip:	Required.Invalid format.
*Home phone:	Required.Invalid format.
Other phone:	Required.Invalid format.
*Work phone:	Required.Invalid format.

*Agency name:	Required.
*Rank:	Required.
*County of agency:	Required.
*State of agency:	Required.
*Start date:	Required.Invalid format.
*Payment Type:	Scroll over the choices for a full description
Monthly Bank Draft $23.50 Yearly Bank Draft $235.00
*Checking or Savings Account:	Please select an item.
*Bank name:	Required.
*Bank routing number:	Required.
*Bank account number:	Required. Please select an item
*Approval to charge:	Required. Please check to approve charges
Donation to the Foundation (Dollar A Month Club):	Required.
*Electronic signature:	Required.
YOU MUST ATTACH A VOIDED CHECK! Please complete this form, print it, sign it, and then mail to: Southern States PBA 2155 Hwy 42 S McDonough, GA 30252 Phone: 800-233-3506