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**Please do not use any work related email addresses. For your security we recommend that you use personal email addresses only such as Gmail, Yahoo, Hotmail etc..

Contact Information

Membership Detail

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Billing Information


* Membership dues include a $.50 per month contribution to our PAC fund. If you do not wish to pay this contribution, please call our office at 800-233-3506.

* In an effort to make your life a little easier, we are now offering paperless billing. After you have signed up for this feature, you will be e-mailed a reminder each time your account is due. If you do not register for paperless billing, you will continue to receive your statement by mail. * Paperless billing is for monthly and yearly invoicing payment types only.

Initiation Invoice

$0.00

Bank Account Info

You have elected to have your membership dues drafted from your bank account once a month. You can expect that draft to be around the 21st of each month. The charge will appear on your bank statement as an "ACH Debit". If you have an outstanding balance, it will be drafted on your first draft.
You have elected to have your membership dues drafted from your bank account yearly. The charge will appear on your bank statement as an "ACH Debit". If you have an outstanding balance, it will be drafted on your first draft.

Signature

I understand that this authorization will remain in effect until I cancel it in writing, and i agree to notify Southern States PBA in writing of and changes in my account information or termination of this authorization. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

If payment is returned because of insufficient funds, I authorize Southern States PBA to draft two month's dues the following month. If payment is returned two consecutive times, you will be changed to regular invoicing.

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