Backmountain Gas - Automatic Payment Plan Authorization

Automatic Payment Plan Authorization

Thank you for your interest in our Automatic Payment Plan. Under this payment plan, you authorize your financial institution to pay your bill. This process is secure and we don’t have to access your bank balance. The amount you authorize is simply transferred from your bank to ours. Complete the application below and return it to us along with a voided check from your checking or preprinted deposit slip from your savings account. The automatic funds transfer will normally begin within 30 days after receipt of your application. I hereby authorize Back Mountain Gas, to initiate debit entries to my Bank and account number indicated below, hereinafter called Bank, to debit the same to such account.

Personal Information

*= Required Field

Name (as shown on bill)*:

Account #*:

02 -

Address*:

City*:

State*:

Zip*:

Daytime Phone*:

Bank Account Information

Bank Name*:

Type of Account*:

Bank Transit/ABA#*

Payment Terms

Account #*:

Payment Date:

of every month.

Amount:

Delivery Customers

Payment on Delivery:

of every month.

Full Name*:

Date*:

Customer Acceptance Signature*:

*(By typing your name in the box above, you are signing, and accepting this agreement) I understand that I am in full control of the automatic payment plan. If at any time I decide to discontinue it, I will notify Back Mountain Gas.. I understand this information will be used solely for the purpose of the automatic payment plan.