Student Name:
*
First Name
Last Name
Account Holder Name
*
Call Phone Number:
*
Format: (000) 000-0000.
Account Type:
*
Checking
Savings
Bank Account Number:
*
Routing Number:
*
Amount (Monthly): $
Base Fee: $400 - Additional Sibling: +$200 per sibling
AUTHORIZATION FOR MONTHLY FEE PAYMENTS
I hereby authorize Darul Uloom Michigan to initiate monthly fee payments.
This agreement remains in effect until I notify Darul Uloom Michigan in writing of any changes.
I understand that the withdrawal of my child from Darul Uloom Michigan is not permitted during the middle of the academic year. If I withdraw my child, I am responsible for paying the monthly fees until the end of the academic year. If the direct deposit is canceled by me or my bank, I will be responsible for paying any applicable cancellation fees.
By signing below, I acknowledge that I have read, understand, and agree to the above conditions.
Signature
*
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: