I (we) hereby authorize Felfam LTD, hereinafter called company, to initiate debit entries to my (our) checking account indicated below and the bank named below, hereinafter called bank, to debit the same to such account.

Coompany Name:

Bank Name:

City:

State:

Bank Routing #:

Account #:

Account Type:
CheckingSavings

Email:

Address:

Phone #:

I authorize Felfam LTD or its assigns, with prior authorization to initiate debit entries at the above named financial institution for all sums required to fulfill our monthly contractual obligation referenced above, including current assessments. A copy of this form will be kept on file and made available to all interested parties. Felfam LTD agrees to notify upon discovery of any errors resulting from transaction under this authorization. I agree to notify Felfam LTD immediately of any changes that may affect these instructions or our ability to rely upon them.

This authorization may be cancelled upon written notification in such a manner as to afford Felfam LTD or its assigns and the above named bank a reasonable opportunity to act on it. Any such cancellation shall be effective only with respect to entries initiated after the financial institution’s receipt of such notification.

Signed:

Date: