Electronic Debit Form

ACCOUNT HOLDER INFORMATION:

Name*

First Name

Last Name

What is your CVE Address? (Building, Letter, Number)*

Address Line 1

State/Province

Zip Code

Phone Number*

Secondary Phone Number

Email*

Debit Start Date MONTH*

Debit Start Date YEAR*

Type of Bank Account*

Checking Savings

I owe fees from previous months and would like to use this account to satisfy my balance. *

Yes, please! No, I will pay another way.

Account Holder Agreement: I, the account holder, have included a photo of a Blank Voided Check (Must be a bank located within the Continental United States) and hereby authorize my financial institution to debit my account in the make of the entity indicated above. I understand this debit will appear on my bank statement between the 5th and 10th day of each month. In addition, I understand this auto debit will be valid until I notify the entity indicated above in writing 30 days prior to canceling the auto debit. I also give the entity indicated above the authority to increase the auto debit as the Board of Directors increases the maintenance fees.*

I understand and agree to the above statement.

Account Holder Signature*

[clear]

Upload Voided Check Here*

No File Chosen

File uploads may not work on some mobile devices.

Pro Tip: Take a picture on your phone and you can upload directly online!