JFORCE Payment Authorization Form - Levine Jewish Community Center, Charlotte, NC

Single or couple

Participant Name

Participant Spouse/Partner Name (if applicable)

Program

JFORCE only JFORCE and Nutrition

Beginning Month

Number of Months (leave blank if indefinite)

Payment method -- select one --

Credit Card:I authorize the Sandra and Leon Levine Jewish Community Center (Levine JCC) to initiate transactions to my credit card on file with the LJCC for JFORCE or JFORCE and Nutrition monthly payments. I authorize the credit card institution to charge my account for the amount indicated on the first business day of each month. I understand that prices may increase annually and it is incumbent on me to make myself aware of those changes. Bank Account: I authorize the Sandra and Leon Levine Jewish Community Center (Levine JCC) to prepare and execute a bank draft or EFT for JFORCE or JFORCE and Nutrition monthly fees. I authorize my banking institution to debit my account for the amount indicated. I understand and agree that if I close my account or stop payment on my bank draft or EFT that I will be obligated to pay the balance of my fees immediately. If for any reason my draft should not be honored I will be responsible for that draft amount plus a $25 service charge. I understand that my account will be drafted on the first business day of each month. I understand that prices may increase annually and it is incumbent on me to make myself aware of those changes.

I understand that I am paying for ongoing program service fees for JFORCE or JFORCE and Nutrition for myself and my partner/spouse (if paying a couple rate). If I choose to terminate the program services provided to me, I will inform the Levine JCC in writing 30 days prior to the termination date. I further understand that the authority of this payment authorization will remain in effect until the payment period indicated in this form or until my written termination is received by the Levine JCC. I agree the Levine JCC shall be fully protected in honoring such drafts or credit card debits. I understand that there may be price increases in the future and it is incumbent upon me to make myself aware of any such changes. No refunds will be provided based on changes in price.

If I do not already have a credit card nor bank account information on file with the LJCC, I agree that I will contact Kristi Fallowes, Controller, at [email protected] or 704.944.6703, and provide that information prior to my first JFORCE session. If I have multiple cards on file, I will contact Kristi Fallowes to advise as to which credit card I wish to be used for this purpose.

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Printed Name