MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01CB0E2B.A0EB0310" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01CB0E2B.A0EB0310 Content-Location: file:///C:/AAE32669/DOMINIONCCEFTAuthorizationForm(2).htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)

 

THE DOMINION COUNTRY CLUB

AUTHORIZATION AGREEMENT FOR DIRECT DEBI= TS AND CREDITS 

MADE BY EFT (“ELECTRONIC FUNDS TR= ANSFER”)

 

 =

I hereby authorize THE DOMINION COUN= TRY CLUB (“the Club”) to initiate credit and/or debit entries t= o my depository account at the financial institution named below, hereinafter ca= lled Depository. I acknowledge that the origination of EFT transactions to my account must comply with the provisions of U.S. law, and that such transact= ions will be used to settle my monthly billing statements, which will vary in am= ount and will consist of (a) monthly membership dues, (b) usage charges and fees= for goods and services utilized or consumed at the Club or at participating reciprocal clubs, (c) additional fees, dues or charges for elective upgrade benefits I have chosen to participate in, (d) installments payable towards = my Club initiation payment, if I elected to finance such initiation payment, (= e) late fees and charges payable in accordance with the Club’s Bylaws and billing policies, and (f) and other fees or charges which would commonly be billed to my membership account based on my authorization or usage. Not all financial institutions participate in EFT transactions; if my financial institution does not participate, I will not be eligible for this service.<= o:p>

 

Deposito= ry        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      

Name     = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;       Branch

 

City        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;     State        &= nbsp;       Zip

 

Routing<= span style=3D'mso-tab-count:7'>        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            Account

Number  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =       Number

         (9 digit number at bottom left of check)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;             (number to the right of routing number)

 

A voided check must be returned = with this signed form.

 

Your account will be drafted on the = 15th of each month.

 

(NOTE: when the 15th falls on a holid= ay or weekend, draft will occur on the following business day)<= /b>

 

This authorization is to remain in full= force and effect until the Club has received written notification from me of its termination in such time and in such manner as to afford the Club and Depository a reasonable opportunity to act on it. I acknowledge that the Cl= ub reserves the right to discontinue EFT service at any time.

 =

Name   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;        Member Number

           &n= bsp;            = ;            = (Please Print)

 

Signature     =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            = Date

 

 


Signature __________________________________________   Date     _________________________

   &nbs= p;            &= nbsp;               =     (If Joint Account)

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