I authorize PONDEROSA TELEPHONE and the financial
institution named below to deduct the amount of my monthly telephone bill
from my bank account. I understand my automatic payment will be deducted
on the 10th business day of each month. I understand that both PONDEROSA
TELEPHONE and my financial institution reserve the right to terminate this
authorization and my participation therein. If I choose to terminate this
authorization, I will immediately notify PONDEROSA TELEPHONE. By signing
this enrollment form, I confirm that I have reviewed and accepted the
Terms and Conditions of the Ponderosa Auto-Pay service.
Customer
Information:
Name:
Address:
City/St/Zip:
Ponderosa
account to be paid:
Ponderosa
account to be paid:
Daytime
Phone:
Bank
Draft Information:
Name
of Financial Institution:
Phone:
Please
deduct payments from:
Checking.
You must provide us with a voided check.