Al-Hadi School of Accelerative Learning - ACH Authorization Form

14855 Richmond Ave, Houston, Texas 77082 832-617-8363; Fax 713-513-5315 Email: registrar@alhadi.com

Account Holder Information

Account Holder Name (First, Middle and Last) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Authorization Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Withdraw Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Student Information

Student First Name *
Student Middle Name
Student Last Name *
Grade *
Child {binding ItemNumber}
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Bank Account Information

Account Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Institution Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please see below image where you can find the routing # on the check.

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Please see above image where you can find the account # on the check.

Signature

I hereby authorize ANJUMAN-E-HAIDERI d.b.a AL-HADI SCHOOL to charge my Bank Account listed here in the amount of stated above.

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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Disclaimer

This authorization is to remain in full force and effect until Al-Hadi School has received written notification from me (or either of us) of its termination in such time and such manner as to afford Al-Hadi School a reasonable opportunity to act on it. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Al-Hadi School may, at its discretion, attempt to process the charge again within 30 days, and I agree to reimburse Al-Hadi School for any charges incurred by Al-Hadi School for the ACH Transaction rejection.

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Al-Hadi School of Accelerative Learning - ACH Authorization Form

Al-Hadi School of Accelerative Learning - ACH Authorization Form

14855 Richmond Ave, Houston, Texas 77082 832-617-8363; Fax 713-513-5315 Email: registrar@alhadi.com

Account Holder Information

Account Holder Name (First, Middle and Last) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Recurring Monthly Payment Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Authorization Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Withdraw Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Withdraw Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Withdraw End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Student Information

Student First Name
Student Middle Name
Student Last Name
Grade
Child {binding ItemNumber}
Student First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Student Middle Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Student Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Grade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bank Account Information

Account Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Institution ( Bank or Credit Union Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Institution Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Routing Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Signature

I hereby authorize ANJUMAN-E-HAIDERI d.b.a AL-HADI SCHOOL to charge my Bank Account listed here in the amount of stated above.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Disclaimer

This authorization is to remain in full force and effect until Al-Hadi School has received written notification from me (or either of us) of its termination in such time and such manner as to afford Al-Hadi School a reasonable opportunity to act on it. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Al-Hadi School may, at its discretion, attempt to process the charge again within 30 days, and I agree to reimburse Al-Hadi School for any charges incurred by Al-Hadi School for the ACH Transaction rejection.

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