Account Information (Please Choose One) - JAMSpiritSites.com

Responsible Name:

Athlete Name:

Responsible Address:

Responsible SSN: Email:

City, State, Zip

Cell #:

Home #: Monthly Tuition Amount



Draft Day each Month 1st

First Draft Amount

Withdrawal Begin Date Month

Day

Year



Account Information (Please Choose One) ( ) Checking ( ) Savings Name on Account: Routing #:

( ) Credit Card Name on Card:

Card Type:

Bank Account #:

Card #:

Bank Name

Expiration Date:

Security Code:

I hereby authorize Arkansas Cheer Dynamix to initiate debit entries to the account indicated below via auto---pay draft system. I understand that beginning on the date listed above, Arkansas Cheer Dynamix will begin withdrawals from my bank account or credit card account. Such withdrawals will continue each month until the athlete is no longer on team or I have requested to stop auto pay draft. This form of payment can be used to pay for any items charged to my ACD account. I am aware of the $20 charge that will occur if I choose to use a credit card to draft my tuition. I further agree that should Arkansas Cheer Dynamix be notified that funds are not available in my bank account (NSF, closed account, etc.) or that a change to my account is denied, a $25 fee will be charged. I understand if I choose to discontinue this method of payment I must notify Arkansas Cheer Dynamix a minimum of seven days prior to my scheduled debit date. Signature: ___________________________________________________________ Date: ________________________________