We offer Electronic Account Debit for your
convenience. If you would like to take advantage of this
payment method, please print and fill out the form
below then mail or fax it back to us.
You may switch
payment methods at anytime. You also may choose to do a
one-time debit to your account or have your account debited
automatically. Please feel free to contact us at
800-869-0922 if you have any questions concerning this new
method of payment. Please include a voided check with
this form.
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Name ______________________________
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Username __________________________
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I (we) hereby authorize ___________________________________,
hereinafter called NetOne Communications, Inc., to initiate debit entries
to my (our) Checking Account / Savings Account (circle one)
indicated below at the depository financial institution named below, and
to debit the same to such account. I (we) acknowledge that the
origination of ACH transactions to my (our) account must comply with the
provisions of U.S. law.
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Depository Name ___________________
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Branch ____________________________
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City ______________________________
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State __________
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Zip ____________
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Routing Number ____________________
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Account Number ____________________
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This authorization is to remain in full force and effect
until NetOne Communications, Inc. has received written notification from
me (or either of us) of its termination in such time and in such manner as
to afford NetOne Communications, Inc. and Depository a reasonable
opportunity to act on it.
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| Name(s) ___________________________ |
Username __________________________ |
(Please Print)
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Date_______________________________
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Signature__________________________
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