Form

ACH Debit Authorization

Name

Email Address

Phone Number

Street Address

City

State

Zip Code

Name of Financial Institution

Type of Account

Routing Number

Account Number

Recurring Donation Amount

$

Frequency of Recurring Donation

I authorize the Junior League of Salt Lake City to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the company a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution 3 days before my account is charged.

Cancel