ACH Collection Authorization Form

I ______, from the business known as ______, authorize the employees of Greater Northwoods MLS, Inc. to automatically withdraw our membership dues, on a monthly basis, from the account listed below. I acknowledge that by signing below, I am indicating that I have the authority to grant such transfers from our deposit account listed below. By signing below, I also acknowledge that to modify or rescind this agreement, I must do so in a matter that is acceptable to the Greater Northwoods MLS, Inc. Please return a voided check with this completed document, for verification purposes.

1. Name of organization from which funds will be transferred:

______.

2. Name of financial institution which deposit account is located:

______.

3. ABA Routing Number of the above financial institution:

______.

4. Deposit account number:

______.

5. Amount of funds to transfer per month.

______.

SIGNATURE OF AUTHORIZED DEPOSIT ACCOUNT SIGNER

______