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Credit/Debit Card/ACH Authorization I hereby authorize the City of Laramie to debit my credit card/bank account $ per month for the payment of my Recreation Center membership and fees. I hereby authorize the City of Laramie to charge any outstanding balance due to this account. Terms of Agreement: 1. This credit/debit card/ACH authorization is to remain in effect until all payments have been withdrawn for my membership. 2. To assure proper processing, change of credit/debit card/ACH information must be received in writing 30 days in advance. To change information, return this form to the City of Laramie, Parks & Recreation, P.O. Box C, Laramie, WY, 82073. 3. Each occurrence of a payment refusal will result in a minimum $25 processing charge in addition to the collection of the fee. Balances due must be paid in cash, cashier’s check or money order within 10 days of notification of payment refusal. Membership privileges will be suspended after the 10-day notification period. Debits not clearing your account for two consecutive months will result in membership cancellation, with the entire balance on your membership due. Payment may then be made with cash, a cashier’s check or money order. 4. The City of Laramie reserves the right to cancel this agreement at any time. Signature of Account Holder: Date Signed: Signature of parent/guardian (for those under age 18): Date Signed: For Parks & Recreation Use Only: Received by (initial): Date of Receipt: Submitted to Financial Institution by (initial): Date of Submission: **Attach a voided check here (do not use a deposit slip) CITY OF LARAMIE PARKS & RECREATION P.O. Box C / 920 Boulder Drive Laramie, WY 82073 Phone: (307) 721-5269 Fax: (307) 721-5284 Email: [EMAIL REDACTED] SIGN SIGN