Membership Application 2019-2020

This application is for member payment through ACH bank account direct debit.

Membership is automatically renewed for 2018-2019 members paying by direct debit or PayPal auto pay. Automatically renewed members do not need to complete this form.

Name (as shown on bank account): *

Personal Email *

College *

Office Phone: *

Home/Cell Phone: *

Home Address: *

City: *

State: *

Zip: *

ACH direct debit frequency: * 🛈

Are you switching to ACH from PayPal? * 🛈

Yes, I'm switching.

No, I'm not.

Optional: Amount of Faculty Foundation Contribution (debited at the same time and on the same schedule as dues deduction)

Optional: Amount of Faculty PAC Contribution (debited at the same time and on the same schedule as dues deduction)

AUTHORIZATION AGREEMENT FOR ACH DIRECT DEBIT

I authorize Maricopa Community Colleges Faculty Association (MCCFA) to initiate debit entries to my account indicated and the named depository financial institution named to debit the same such account for payment of my Faculty Association dues. This authorization is to remain in full force and effect until MCCFA has received written notification from me of its termination in such time and in such manner as to afford MCCFA and my financial institution a reasonable opportunity to act upon it. If an ACH debit should be returned or dishonored by my bank for any reason, MCCFA is authorized to re-attempt the payment and include reimbursement of any fees incurred.

Bank Name: *

Routing Number (nine digits on lower left of check -- NOT DEPOSIT SLIP): *

Account number (on lower right of check): *

Account Type: *

Today's Date: *