VIRGINIA TECH FOUNDATION, INC.
Authorization for Pre-Arranged Payments (ACH Debits)

I (We) hereby authorize the Virginia Tech Foundation Inc. to initiate debit entries and/or correction entries to our

New Update (Please select one)
Checking account or Savings account (Please select one)

indicated below at the depository (e.g. bank, credit union) named below,

herein after called DEPOSITORY, to debit the same account.
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DEPOSITORY (BANK, CU) NAME
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BRANCH
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CITY
___________________________________
STATE
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BANK TRANSIT/ABA NUMBER
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ACCOUNT NUMBER
This authorization is to remain in full force until the Virginia Tech Foundation, Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Virginia Tech Foundation, Inc. and DEPOSITORY reasonable opportunity to act upon it.
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NAME(S)
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SIGNATURE
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DATE
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SIGNATURE
___________________________________
DATE
___________________________________
ADDRESS
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CITY
___________________________________
STATE
___________________________________
ZIP
Amount: $____________ per month
Begin Deduction on: ________________(month) 15 / 30 (day) __________ (year)
Please attach a voided check if using a checking account or a deposit slip if using a savings account. Return the form and all attachments to Sharon Linkous, Va. Tech Athletic Fund, P.O. Box 10307, Blacksburg, VA 24062. If you have questions concerning this form, please contact Sharon Linkous at (540) 231-5851.