Section 1 of 1 in this document

Community Recreation Center Bank Draft Form

Member Information

Phone

Bank Draft

Bank draft action

Authorize/Modify

Hold

Cancel

Do you have an existing bank draft with the Community Recreation Center?

Yes

What modification are you making?

Statement of Authorization

I hereby authorize the City of Pocatello Finance Department to draft my bank account monthly for the amount of service billed by the City of Pocatello Community Recreation Center. I authorize the financial institution listed on the attached voided check to debit such amounts from my account as indicated below.

Bank account type

Checking

IMPORTANT: You must include a VOIDED CHECK or PROOF OF ROUTING AND CHECKING ACCOUNT NUMBERS front your bank including your name, bank name, routing number, and checking account number so that this request can be processed.

Voided check (or proof of routing and account numbers)

Click Here to Upload

Draft amount

$30 – Adult

$44 – Couple

$50 – Family (2 adults, 1 child)

$56 – Family (2 adults, 2 children)

$62 – Family (2 adults, 3 children)

$68 – Family (2 adults, 4 children)

$74 – Family (2 adults, 5 children)

$80 – Family (2 adults, 6 children)

Draft begin date

Acknowledgement

I acknowledge that this authorization remains in effect until the City of Pocatello Community Recreation Center receives my written notice of cancellation. To stop an upcoming debit payment, I must notify the Recreation Center in writing NO LATER than 5:00 pm on the 24th of the month PRIOR to my next scheduled payment. For assistance or to dispute charges on my Recreation Center bill, I will contact the City of Pocatello Community Recreation Center at 208-232-3901 x2200.

Hold date cannot be more than six (6) months from today.

Hold until date

Form must be received NO LATER than 5:00 pm on the 24th of the month PRIOR to your next scheduled payment.

Draft end date

Cancellation Request

I hereby request the City of Pocatello Finance Department to discontinue drafts of my bank account as payment of my membership. I acknowledge that I am responsible to remit payment to the City of Pocatello Community Recreation Center by another method of my choice.

Signature (as shown on bank records)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

List of Members

Please list the names and dates of birth for all members on your account including yourself, your spouse, and your dependent children under 18 years of age.

Main Member

First Name *

Last Name *

Date of Birth *

Spouse

First Name

Last Name

Date of Birth

Child #1

First Name

Last Name

Date of Birth

Child #2

First Name

Last Name

Date of Birth

Child #3

First Name

Last Name

Date of Birth

Child #4

First Name

Last Name

Date of Birth

Child #5

First Name

Last Name

Date of Birth

Child #6

First Name

Last Name

Date of Birth

Official Use Only

Date Entered into File

Date Sent to Finance

Community Recreation Center Bank Draft Form

Member Information

Name

Address

Bank Draft

Bank draft action

Do you have an existing bank draft with the Community Recreation Center?

Statement of Authorization

Bank account type

Name as it appears on check (if different from member name)

Voided check (or proof of routing and account numbers)

Draft amount

Draft begin date

Acknowledgement

Hold until date

Draft end date

Cancellation Request

Signature (as shown on bank records)

List of Members

Main Member

Spouse

Child #1

Child #2

Child #3

Child #4

Child #5

Child #6

Official Use Only