Automated Dues Payments

PLEASE PRINT YOUR NAME(S) as they appear on DEPOSITORY account:
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Please charge my/our account $*

on the 20th of each month, to be credited to SMCLA.
Name of your DEPOSITORY (financial institution)*
Your Bank's Address*
Street Address Address Line 2 City State ZIP Code
Your Bank's Phone*
Deposit Transit/ABA Number*
My/Our Account Number*
Account Type*
- Checking
- Savings
Check one
SIGNATURE/S
Date
MM slash DD slash YYYY
Privacy*
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