Brotherhood Legacy Program | Phi Kappa Tau Beta Kappa Chapter

Automatic Donation Agreement Form

This is your authorization to charge my account on the 1st day of every month, beginning with

the month of*

In the year of*

in the sum of*

which will be deposited with Phi Kappa Tau Housing Corporation Beta Kappa Chapter.

Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Type of account*

Checking
Savings

Name of Financial Institution*

ABA / Bank Routing Number*

9 digit number

Account Number*

Min 6 digits - Max 17 digits

This authority is to remain in full force and effect until Phi Kappa Tau Housing Corporation Beta Kappa Chapter has received written notification from me of its termination in such time and in such manner as to afford a reasonable opportunity to act on it or when Phi Kappa Tau Housing Corporation Beta Kappa Chapter determines it necessary to discontinue the automatic payment program. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of US law.

Confirmation

By checkign this box I agree to the stated terms.

Signature*

Placing cursor inside box will turn it into a pen so that you may apply a signature to this form.