Prime Time Automatic Withdrawal Authorization Form Company Customer Name * Account Number * Name of Bank/Financial Institution * Routing Numnber * Authorization Statement: I authorize Prime Time Extended Learning Center to instruct my financial institution to make my payments in the following amount, on or after the 5th of the month beginning in September and ending in June upon full payment of account balance: Dollar Amount * I also understand I may discontinue this authorization at any time by giving written notice to Prime Time Extended Learning Center. I realize this information will be used solely for the purpose of consumer withdrawal. Please check this box to agree to these terms: * I Agree Customer Name/Signature * Date of Signature * Please bring a voided check to your appointment.
