I,
, hereby authorize LifeTrek,
Inc. (d/b/a LifeTrek Coaching International) of 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 USA to initiate an ACH debit entry
to the following USA checking or savings account on a monthly
basis for the Coaching Complete program. I acknowledge that the origination of
ACH transactions to my account must comply with the provision of U.S. law and
that by my submission of the data contained herein I agree to be bound by said
law.
I understand that the amount of each monthly payment is determined by the term
of the program I agree to in the Standard Coaching Complete Agreement and that
the transaction shall be processed on or around the first of every month.
I understand that this payment authorization will be in full force and effect
until the term of my Coaching Complete program has expired.
Note: To authorize an electronic check, you will need to provide
your checking or savings Account number and financial institution Routing
number. Do
not provide your Debit card number (for that you should use the
Credit or Debit authorization form).
The financial institution Routing number can be found on the
Microline at the bottom of a check or deposit slip. It is always 9 digits long, begins with 01–12
or 21–32, and appears between the
characters. It is usually (but not always) the first set of numbers on the check
or deposit slip, as in the numbers
highlighted in red on the following example:
.
The Account number for a checking or savings account can also be
found on the Microline at the bottom of a check or deposit slip. It does not include the check
or deposit slip number, can never
be more than 17 characters long, usually appears before the
character, and may (but does not always) have a dash
between the numbers, as in the numbers highlighted in red on the following
example:
.
Please type where indicated, then print this form, sign, and return to LifeTrek
Coaching
either by mail to: 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 USA or by fax to: (772) 382-3258.
AUTHORIZATION to ACH
Depository Name:
Routing Number:
Account Number:
Customer Name:
Customer Address:
Coaching Complete Term
(Check One):
5-Months
10-Months 15-Months
Customer Phone:
Customer E-Mail:
Today's Date:
Authorized Signature:
After typing where indicated, please print this form, sign, and
return to LifeTrek Coaching
either by mail to:
121 Will Scarlet Lane, Williamsburg, VA 23185-5043 USA or by fax to (772) 382-3258.
characters. It is usually (but not always) the first set of numbers on the check
or deposit slip, as in the numbers
highlighted in red on the following example:
.
character, and may (but does not always) have a dash
between the numbers, as in the numbers highlighted in red on the following
example:
.