I authorize the European Society of Medicine hereinafter named ESMED to initiate a single ACH/electronic debit to my account in the amount shown above from my bank account as entered. Payment will be initiated today or on the next business day.

I agree that ACH transactions I authorize comply with all applicable law.

Checking/ Savings Account                                                

   Checking            Savings

Name on Acct      ____________________

Bank Name          ____________________

Account Number ____________________

Bank Routing #   ____________________

Bank City/State   ____________________                                                

Billing Address ____________________________                  ________________________

City, State, Zip ____________________________

Phone#:                      Email:

I (we) understand that this authorization will remain in full force and effect until I (we) notify ESMED in writing that I (we) wish to revoke this authorization. I (we) understand that ESMED requires at least 2 days prior notice in order to cancel this authorization.