AUTHORIZATION FOR BANK DRAFT

(To be completed and signed by the employee in appropriate space: [please type in the provided spaces and then print the form out])
 
  -   -  
 Social Security Number
E-mail (No work email addresses please)
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County		  
State
 
Zip		  
Home Phone		  
Work Phone

Member's Signature:  Date:

TERMS AND CONDITIONS:  I HEREBY AUTHORIZE my bank/credit card company to make my payment for membership dues to the Southern States P.B.A.I am aware that I retain  full control of my payment and that it will appear on my bank statement.
 

Bank Routing Number:

  

Bank Account Number:
 

Bank Name: