ACH Collection Authorization Form



ACH Collection Authorization Form

I __________________, from the business known as ____________________________, authorize the employees of Greater Northwoods MLS, Inc. to automatically withdraw our membership dues, on a monthly basis, from the account listed below. I acknowledge that by signing below, I am indicating that I have the authority to grant such transfers from our deposit account listed below. By signing below, I also acknowledge that to modify or rescind this agreement, I must do so in a matter that is acceptable to the Greater Northwoods MLS, Inc. Please return a voided check with this completed document, for verification purposes.

1. Name of organization from which funds will be transferred:

___________________________________________.

2. Name of financial institution which deposit account is located:

___________________________________________.

3. ABA Routing Number of the above financial institution:

___________________________________________.

4. Deposit account number:

_________________________.

5. Amount of funds to transfer per month.

__________________.

SIGNATURE OF AUTHORIZED DEPOSIT ACCOUNT SIGNER

_______________________________________

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