Monthly Membership Pre-Authorized Payment

Member Name:  

Membership Number:  

Monthly Membership:  

Membership Discount:  

Account Holder Information 

Bank Account Holder's Name:



Bank Information (New or updated Information)

Name and Location of Financial Institution:  

Account Number: xxxxx xxx  


I/We hereby authorize Jeon Eui Taekwondo to direct my Financial Institution to debit my/our bank account, on file, as follows:

  1. Membership withdrawal date on  reflect the pro-rated membership of the month.
  2. Monthly Membership Fees will be withdrawn on the 1st day of each month.
  3. May be cancelled upon 15 days of written notice by me/us being provided to Jeon Eui Taekwondo.
  4. If any payment is returned by the Bank for any reason, I/we will be responsible for Non-Sufficient Funds (NSF) and/or administration charges.
  5. We acknowledge that the amounts to be drawn against our Account may vary in accordance with the membership type and condition in the amounts billed Jeon Eui Taekwondo.

I/We, the undersigned, have read, understood, and agree to the terms and conditions of this agreement.


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Signature Certificate
Document name: Monthly Membership Pre-Authorized Payment
lock iconUnique Document ID: e62854996af544e0d402f4d28c86689918f9bb39
Timestamp Audit
March 29, 2022 5:06 pm PDTMonthly Membership Pre-Authorized Payment Uploaded by Lois Fong - IP