Fillable Recurring Payment Authorization Form printable pdf download

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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

Visa

MasterCard

Checking

Savings

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) ______

SIGNATURE

DATE

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account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted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.