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 the month Enrollment starts and ending upon official withdraw from Prime Time. I also understand that I may discontinue this authorization at any time by giving written notice to Prime Time at least 2 weeks prior to the beginning of next month when withdrawing from Prime Time.
Customer's Signature*

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Date*

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Prime Time Extended Learning Center Automatic Withdrawal Authorization