Automatic Debit Authorization

AUTOMATIC DEBIT

AUTHORIZATION

I now authorize the St. Tammany West Chamber of Commerce to make automatic debits from my account at:

BANK NAME: ______

AMERICAN BANKER'S ASSOCIATION ROUTING # :______(9 DIGITS)

DEPOSITOR'S ACCOUNT NUMBER: ______

ACCOUNT IN THE NAME OF: ______

The automatic debit will be in the amount of $______and will occur on or about the 15th of each month.

I understand that I may stop payment of any automatic draft from my account by notifying the Bank orally or in writing at any time up to 3 business days before the scheduled date of the transfer. The Bank may require written confirmation of the stop payment order to be made within 14 days. If an oral notification is made, this requirement is disclosed to me together with the address to which confirmation should be sent. If written confirmation has been required by the Bank, the oral stop payment order will cease to be binding 14 days after it has been made. This authorization may be terminated by me at any time by giving written notice to the St. Tammany West Chamber of Commerce.

CUSTOMER NAME: ______

CUSTOMER SIGNATURES: ______

DATE: ______

Membership Tier / Number of Employees / Annual / Monthly
Business Level 1 / 1-5 employees / $300 / $25.00
Business Level 2 / 6-10 employees / $350 / $29.17
Business Level 3 / 11-30 employees / $475 / $39.58
Corporate Level / 31-50 employees / $825 / $68.75
Tower Level / 51-75 employees / $1,500 / $125.00
Executive Level / over 76+ employees / $3,000 / $250.00
Affiliate / secondary location / $120 / $10.00
Citizen’s Choice / Non-business / $125 / $10.42
Organization / Civic, charitable or gov’t org. / $250 / $20.83

For questions, please contact:

Melissa Dottolo, Director of Membership & Marketing

or 985-273-3002