Authorization for Pre-Authorized Debit

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This form is used to authorize a set amount to debit from an account.
Parent/Guardian Name(Required)
Student Name(Required)
MM slash DD slash YYYY
Preauthorized debit(Required)
I confirm the school has my pre-authorized debit information (banking information) and I authorize the school to debit the amount as indicated above within one month of receipt of this authorization.
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