Prime Time Automatic Withdrawal Authorization Form

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:

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 bring a voided check to your appointment.