Click here to view the ACM Membership Payment Options below.
* - denotes a required field
By the submitting this agreement, I, the participant, hereby authorize Ceraland Park to initiate debit / charge entries to my checking / savings account at the Financial Institution named on my attached voided check and to debit the same to such account.
Disagree Agree
I understand that I have authorized payment for a minimum of a one year (12 month) term (pursuant to the agreement on my attached signed Employee Data Form). I may elect to discontinue my membership only after the 12 month term has elapsed.
My checking / savings account will be drafted for $ * on the (select one date) 15th or 29th of each month. My first draft will occur in (Month) , (Year) .
I understand that I may not cancel within the first 12 months of membership unless I notify Ceraland Park at least 15 days prior to the drafting date by completing a written cancellation request and making payment in full for the remainder of the membership fee. DO NOT CALL YOUR BANK TO CANCEL, THIS MUST BE COMPLETED THROUGH CERALAND ONLY.
I understand that any NSF (non-sufficient funds) transactions will be assessed a $20 fee and processed through my account no more than twice. The membership will be cancelled and legal action will be taken if the monthly payment and NSF fee is not collected by the second attempt. Should the account be referred for collection, the applicant shall pay reasonable attorney's fees and costs of collection.
New EFT I agree to fax a voided check or deposit slip from my account listed above to CERA at 812.377.6408 on this date.
Renewal EFT Please enter initials if renewing & using the same account information.
By submitting this form, I acknowledge that I have read and understand the above agreement.
Applicant's Name * (By filling in your name, you are acknowledging the same as a written signature of acceptance)
Date Submitted
