* = required field
  Full Name: *  
  Address: * Address 2:
  City: * State: *
  Zip: * Telephone: *
  Email: Last 4 Digits
of SSN:
  Name Of Your Bank: * Account Type: *
  Routing Number: * ( ? ) Account Number: * ( ? )
  Check Number: ( ? ) Membership Type: *
  - Add Additional Driver ( + $25/year)    
  - Add RV Coverage ( + $40/year) IP Address:


I authorize Smart Member Services LLC. to debit the bank account indicated in this web form, for the noted amount on the schedule indicated.  I understand that this authorization will remain in effect until the schedule end date, or until I cancel It, which ever comes first, and I agree to notify Smart Member Services LLC. of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date.  I understand that the payment will be executed 30 business days after I submit this authorization.  If the above noted authorization falls on a banking holiday then the transaction will occur on the next business day.  I understand that because this is an electronic transaction, these funds may be withdrawn from my account each month as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process the charge again within 30 days, and agree to an additional $15 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I will not dispute the company’s recurring billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.
Select Print on your Browser to print and retain a copy of the authorization.


By checking the box to the left, I understand the terms and conditions and the clicking the "authorization" button below, I confirm that I am the owner of the account identified by the numbers entered above and authorize this merchant to convert my account information entered above into an electronic debit to, my account for the amount of this transaction.


I understand that a penny (.01$) credit will be applied to my account 4 business days before the initial scheduled bill date in order to verify my account's validity and by accepting this credit I am authorizing Smart Member Services LLC. to debit my bank account unless cancellation is received in accordance with the terms and conditions.