Authorization and Agreement Form
Authorization for Electronic Funds Transfer and Acceptance of Member Agreement.
To complete the Association's registration:
 Print out this form, complete and sign it.
Then fax it to us along with a copy of your voided check and a copy of your current license. Our fax number is (888) 582-7026.

If you are unable to fax them, notify us by email, and send them to:
ProfessionalCharges.com 
1530 E. Chevy Chase Dr., Suite 209
Glendale, CA 91206
Bank Information

Name(s) on Bank Account:___________________________________

Checking Account Number: _____________________________

Bank Routing Number: __ __ __ __ __ __ __ __ __ 
(The 9 digits on your check to the left of the account number.)

We authorize ProfessionalCharges.com to initiate credit entries (deposits) and debit entries (withdrawals from), and to initiate if necessary adjustments for any credit or debit entries in error to my account indicated above and the bank depository named above to debit and/or credit the same to such account. 

We certify that all information submitted is and will be true and correct. This authorization is to remain in full force and effect until it is terminated according to the terms of the Membership Agreement we have with ProfessionalCharges.com. 

The undersigned certifies that the business meeting or governing board has adopted an approval resolution authorizing us to accept and sign the Member Agreement by placing our signatures on this Authorization and Agreement Form. It is with the express understanding that the governing body or board, and the officers, represented by the undersigned, shall be responsible for the guaranteeing of all obligations set forth in the Member Agreement.  
President: Administrator/Secretary/Treasurer:

____________________________________


____________________________________

Print Name

 ____________________________________

 Print Name and Title
____________________________________

Signature

 Signature:

Social Security No.____________________
Social Security No.____________________
Driver's License No.____________________
Driver's License No.____________________

Home Address:________________________
Home Address:________________________

____________________________________
____________________________________
____________________________________
____________________________________

Home Phone:_________________________
Home Phone:_________________________

Date:__________________
Date:__________________

E-mail of Contact Preson:______________________________________