I, Student Guardian, do hereby authorize the above named merchant to initiate a debit/credit, in the amount below, to my checking/saving account at the depository financial institution (Bank) identified by the routing number below and bank to debit same to such account.I acknowledge that I have received service/goods in consideration hereof and I further agree that this authorization shall be non-revocable. I agree to pay merchant a returned item fee in accordance with the merchant's return policy, which may be initiated to my account for the items returned unpaid.
I further acknowledge that I have completely read, understand, and received a copy of this agreement.