Howell Dance Company – Checking Account Debit Authorization Fields that have an * are required. This form allows Howell Dance Company to have your child's tuition taken out of your checking account monthly from Sept. 2023 to May 2024You must upload a photo of a Voided Check at the end of this form.Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Checking Account InformationPlease debit payments from my checking account, below.Routing Number* Valid Routing # must start with 0, 1, 2, or 3Account Number* Consent - authorization* I authorize Howell Dance Company to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notification to terminate the authorization.Consent - same checking account I authorize Howell Dance Company to continue using the same checking account that is already on file from the previous school year.Consent - late fee* I understand that Howell Dance Company will debit my checking account for any outstanding costume, accessory or any competition fees not paid by the due date with a $10 late fee.Upload a photo of a VOIDED check.*Max. file size: 50 MB.Your Name - As Your Digital Signature* PhoneThis field is for validation purposes and should be left unchanged.
