AUTOMATED PAYMENT AUTHORIZATION FOR LOST CITY GOLF CLUB MEMBER ACCOUNT Please complete the information below or send us a voided check from the account you wish the funds drawn, then sign and date at the bottom and return this form. Payments will automatically be made on the 15th of each month, or the next business day after. *************AUTOMATED PAYMENT AUTHORIZATION************ _________________________________________________________________________________________ Member Name: __________________________________ Hereby authorizes Atlantis Golf Club d/b/a Lost City Golf Club to initiate debit entries to our bank account indicated below at the bank named below and authorizes the bank to debit the same to such account for amounts due to Lost City Golf Club. Bank Name: _______________________________ Branch: ____________________________________ City: ______________________________ State: ______________ Zip Code: _____________________ ABA Routing Number: _______________________ Account Number: ____________________________ Name Address
City, State, ZIP
Pay to the order of
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Bank. Name
1
Account Number ABA Routing Number
This authorization is to remain in full force and effect until Lost City Golf Club has received written notification from us of its termination in such time and in such manner as to afford Lost City Golf Club and bank a reasonable opportunity to act on it. You agree that a facsimile copy of this agreement bearing signatures may be treated as an original. Date: _____________ Member Name: _______________________________________ Member Number: ______________ Date Automated payments to begin: ______________________ By (Authorized Signature for Bank Account): ___________________________________________