Automatic Payment Form

Personal Information
Billing Name*
Billing Address*
Account Number*
Phone Number*
Format: (000) 000-0000.
Automatic Payment
Financial Institution*
Branch*
City*
State*
Zip*
Financial Institution Routing Number*
On the bottom left of your check
Account Number*
Type of Account*

CheckingSavings
What day of the month do you want the automatic payment withdrawn?*

3rd of the month15th of the month
Do you want your monthly bills emailed to you?*

YesNo
Email Address*
I authorize Grantsburg Telcom and the financial institution named above to initiate entries to my checking/savings account. This authority will remain in effect untill I notify you in writing to cancel it in such time as to afford Grantsburg Telcom and the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying Grantsburg Telcom three (3) days before my account is charged.
Signature*
Date*

MonthDayYear
*
Should be Empty: