Authorization and Agreement Form

Authorization for Electronic Funds Transfer 
and Acceptance of Member Obligations.
To complete your membership 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 
201 N. Brand Blvd, Suite 200
Glendale, CA 91203
Bank Information

Name(s) on Bank Account:___________________________________

Checking Account Number: _____________________________

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

I 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. This authorization is to remain in full force and effect until it is terminated according to the terms of the Membership Agreement I/we have with ProfessionalCharges.com. 

I certify that all information submitted is and will be true and correct. I understand and agree to the terms of the Member Agreement, and I am personally guaranteeing all member obligations set forth in the Member Agreement. 


Signature:___________________________________________________________

Date:___________________

E-Mail Address:___________________________________________