Eta Iota Chapter of Sigma Chi, Daytona Beach, FL

Electronic Bank Draft Authorization (checking or savings accounts)

This form supports both one-time and repeating payments.

Please provide some basic information, which will be transferred to our on-line check processor (www.speedchex.com) where you will complete your banking account details on a secure server.

Name
Address 1
Address 2
City
State
Zip
Phone Number	(10 digits)
E-mail Address
Contribution Type	Single Payment Monthly Payment
For Monthly Payments:	The first payment is processed without delay. Enter the preferred day of month to process subsequent payments

Contribution Level
or.... Other Amount $

To adjust or cancel an active repeating payment, please complete the form using the new amount.

To request adjustments to incorrect charges, contact the Eta Iota House Corporation Treasurer below.

If you desire to make the payments yourself (e.g., though a billpayer service, or manually), make the check payable to Eta Iota House Corporation and mail to the address below.

Kyle Stuhlweissenburg "Second String "
241 Riverside Dr
Unit 710
Holly Hill FL 32117