Name *

First Name

Last Name

Phone *

(###)

###

####

Effective Date *

The date on which you would like your withdrawals to begin (Please allow 3 working days to process authorization).

MM

DD

YYYY

Authorization *

I hereby authorize BROADWAY BAPTIST CHURCH, hereinafter called BROADWAY, to initiate debit entries to my Checking Account/Savings account indicated above at the depository financial institution named above, hereafter called BANK and to debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of US law.

Authorization *

This authorization is to remain in full force and effect until BROADWAY has received written notification from me of its termination in such time and in such manner as to afford BROADWAY and BANK a reasonable opportunity to act on it.

Authorization *

By checking this box and typing my name below, I am electronically signing my application.

Electronic Signature *

I certify that all of the information above is to the best of my knowledge and belief true, correct and complete.

First Name

Last Name