Loudoun Chamber ACH Debit Form

Loudoun County Chamber of Commerce
ACH Debit Authorization Form

I (we),__________________,  hereby authorize the Loudoun County Chamber of Commerce, hereafter called COMPANY, to initiate debit entries to my (our) Account indicated below and the financial institution below, hereafter called FINANCIAL INSTITUTION, to debit the same to such account for ITEM listed below.  I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

(Financial Institution Name)                                                                                           (Branch)

(Address)                                                                (City & State)                                                                          (Zip)

___________________________          ______________________________       __Checking  __Savings
(Routing Number)                                                (Account Number)

Frequency                 ____Monthly        ____Quarterly

Account Type           ____Business        ____ Personal

Amount:                  $ _________________

Start Date:                _____________                           End Date:        ________________

Item:          Membership Dues

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such a time and manner as to afford Company and FINANCIAL INSTITUTION a reasonable opportunity to act on it.

(Print Individual Name)                                                                                                     (Signature)

Print Individual ID Number)                                                                                            (Date)

PLEASE ATTACH A VOIDED CHECK TO THIS FORM
For questions or concerns please contact Linda Coffey, Loudoun Chamber
Direct 571-209-9022 or lcoffey@loudounchamber.org