Automatic Debit Authorization

AUTOMATIC DEBIT AUTHORIZATION

INSTRUCTIONS As Easy As 1, 2, 3… 1. Fill out the form below. 2. Attach a voided check. 3. Attach a St. Tammany West Chamber Membership Application. 4. Send both forms to the Chamber via email at [email protected] or fax at 985-893-4244.

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 15 th 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 [email protected] or 985-273-3002