1. Please provide the following contact information:

Student  Name
Phone Number
Email receipts to
Name on Account
Bank Name
Bank Routing Number
Bank Account Number
Bank Account Type	Checking  Savings Business Checking

 

I hereby authorize Merry Melody Music Academy to automatically debit my bank account listed above on the 18^th of each month for the amount owed to Merry Melody Music Academy, Inc. as detailed in the monthly invoice received by the 5^th of the month.

I agree to notify Merry Melody Music Academy in writing of any changes in my account information or termination of this authorization by the 1^st of the month.

I understand that cancellations must be made in writing and I will not dispute Merry Melody Music Academy’s recurring billing with my bank so long as the amount corresponds to terms indicated in this contract.

I guarantee and warrant that I am the legal cardholder/duly authorized check signer on the above account(s), and that I am legally authorized to enter into this recurring billing agreement with Merry Melody Music Academy.

By typing my name, I electronically agree to the terms above and this will stand as my electronic signature.

 

Please type name

 

 
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