Recurring Payment Authorization Form

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Recurring Payment Authorization Form
Schedule your payment to be automatically deducted from your bank account, or charged to your Visa
or MasterCard. Just complete and sign this form to get started!
Recurring Payments Will Make Your Life Easier:
It’s convenient (saving you time and postage)
Your payment is always on time (even if you’re out of town), eliminating late charges
Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your checking/savings account or credit card. You will
be charged the amount indicated on your most current bill. Your account will be charged the last
business day of the month. You agree that no prior-notification will be provided unless the date or
amount changes, in which case you will receive notice from us at least 10 days prior to the payment
being collected.
Please complete the information below:
I ____________________________ authorize The McClure Telephone Company to debit my account
(full name)
indicated below on the last business day of each month for payment of my McClure Telephone bill.
Billing Address ____________________________
Phone# _________________________
City, State, Zip ____________________________
SSN ________________________
Checking/ Savings Account
Credit Card
Name on Acct
Bank Name
Cardholder Name _________________________
Account Number ____________________
Account Number
Bank Routing #
Exp. Date
Bank City/State
CVV (3 digit number on back of card) ______
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The McClure Telephone Company of any
changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates
fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings
account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted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 McClure Telephone
Company may bill a $20.00 charge for any returned NSF. I acknowledge that the origination of ACH transactions to my account must comply with the
provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my
bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.


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Parent category: Business