ACH Authorization This form authorizes RPEN to charge your bank account regularly for payment of your membership dues. You will be charged the amount indicated below in each billing period. A receipt for payment will be provided to you and the charge will appear on your bank statement as an "ACH Debit'" You agree that no prior notification will be provided unless the date or amount of the debit changes, in which case you will receive a notice from RPEN at least ten (10) days prior to the payment debit. I choose to pay my dues:*Monthly - $7.00 per month deducted in the last week of each month.Yearly - $84.00 per year deducted in your RPEN membership anniversary month.Billing InformationBilling Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Bank Detail - Checking AccountAccount Name* First Last Bank Name*Bank Account Number*Bank Routing Number:*Consent* ConsentI authorize Retired Public Employees of Nevada, Inc. to debit my bank account as I have selected for my RPEN membership dues. I understand that this authorization will remain in effect until I cancel it in writing and I agree to notify RPEN in writing of any changes in my account information or termination of this authorization at least fifteen (15) days prior to the next billing date. NameThis field is for validation purposes and should be left unchanged.