Bank Authorization Form

Prime Time Extended Learning Center Automatic Withdrawal Authorization
Customer Name (please print)*
Child/Children’s Name (please print)*
Name of Bank/Financial Institution*
Routing Number*
Account Number*
I authorize Prime Time Extended Learning Center to instruct my financial institution to make my payments in the amount of $ * on or after the 5th of the month beginning in September and ending in June upon full payment of account balance. I also understand I may discontinue this authorization at any time by giving written notice at least 2 weeks prior to the change to Prime Time Extended Learning Center. I realize this information will be used solely for the purpose of consumer withdrawal.
Customer's Signature*

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Date*

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Prime Time Extended Learning Center Automatic Withdrawal Authorization