the 1855 Club Authorization Form

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 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.

Seth Downs
9121 Brewsters Dr
Anchorage AK 99516