ACH Debit Authorization Form

Account Holder's Name * *

Phone Number *

Account Holders Address *

Address Line 1

Address Line 2

City

State

Zip Code

Bank Name *

Branch Address *

Routing Number *

Account Number *

Account Type *

Frequency *

Date To Make Full Single Payment? *

Full Payment Amount *

Total Amount Owed *

Payments Will Be Completed By *

Agree To Terms Below *

I Agree

I hereby agree to pay the Total Amount Owed in full and authorize Off Leash K9 Training to Debit the Bank Account referenced herein, via the Automated Clearing House system, according to the parameters specified herein. This authority will remain in effect until the Total Amount Owed/payment(s) are completed as specified herein. If a payment is returned for any reason I acknowledge that I am subject to a rejected item fee of $25 or the maximum amount allowed by law.

TYPE NAME IN FULL TO SIGN *