Summit Climbing Co.

Membership Office

Auto-Pay Authorization

Set up automatic recurring payments for your Summit membership. Fill this in once and your dues run on schedule — cancel any time.

Member

Member name

Devon Marsh

devon.marsh@email.com

Phone

(555) 442-8810

Membership plan

Summit Annual — All-Access

Payment method on file

Pay with — check one

Credit / debit card Bank account (ACH)

Card type or bank

Visa

Last 4 digits

SAMPLE

Full card / account number — provided securely

•••• •••• •••• •••• Entered securely at the front desk or online — never written here

Amount & schedule

Recurring amount

$59.00

Billed every

Month

First charge date

July 1, 2026

Continues until

I cancel

Authorization

RECURRING PAYMENT AUTHORIZATION

I authorize Summit Climbing Co. to automatically charge the payment method on file for the recurring amount and frequency shown above, beginning on the first charge date and continuing until I cancel. I certify I am authorized to use this payment method.

I understand I can cancel auto-pay at any time by contacting the membership office at least 3 days before the next charge, and that cancelling does not refund charges already processed or waive dues already owed.

I have read and agree to this recurring payment authorization.

SAMPLE SIGNATURE

Member signature

SAMPLE-DATE

Date

Summit Climbing Co. · Fictional auto-pay layout · No payment data is accepted or stored.