Affiliate Member Application

Company Information:

Organization
Address
City State Zip
Phone
Fax
Website

Key Contact Information:

First Name Last Name
Title
Your Email
Your Phone
The membership year runs from January 1st through December 31st and dues are automatically due on January 1st each year with or without notice and the Organization hereby direct PaymentsFirst to debit its account on or after each January 1st in the amount of the outstanding dues owed to PaymentsFirst by the Organization. Unless otherwise terminated by PaymentsFirst, this membership is to remain in full force and effect until Organization has given PaymentsFirst 90–day written notice of its membership termination. Dues are non refundable once the current billing year is in force.
I (we) hereby authorize PaymentsFirst, to initiate debit or credit entries to the transaction account indicated below and the depository financial institution named below, to debit or credit the same to such account.
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