Campus Day Camp Checking Savings Authorization Form

Campus Day Camp Checking/Savings Authorization

Campus Day Camp

2901 Campus Rd. Brooklyn, N.Y. 11210 (718) 421-7575

Child's Name *

CHECKING/SAVINGS WRITTEN AUTHORIZATION FORM

I (we) hereby authorize Campus ASP Inc. to initiate entries to my (our) checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error. A $30 charge will occur if your payment is denied by your bank.

Name of Financial Institution *

Address of Financial Institution *

Address of Financial Institution

Address of Financial Institution

Address of Financial Institution

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Account Type *

Checking

Savings

Routing Number *

Account Number *

Account will be kept on file for future charges.

Amount of *

$

Consumer Name *

Consumer Address *

Consumer Address

Consumer Address

Consumer Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Signature *

Date

If you should need to notify us of your intent to cancel and/or revoke this authorization you must contact us 1 week prior to the questioned debit being initiated. Please call 718-421-7575 or email at info@campusasp.com Monday-Friday from 10:00am to 6:00pm.