Authorization Agreement for Automated Credit Card Payments

 

I (we) hereby authorize EAST BUCHANAN TELEPHONE COOPERATIVE to initiate debit entries to my (our) VISA MASTERCARD  DISCOVER account indicated below.
Card #: __________________________________ Expires: __________  CSV #:________
 
Primary Name: __________________________________________________________________
Accounts to be debited: _________________________
  _________________________
  _________________________
Credit Card Payment Date: ____________________________________________________
Signature: ______________________________________ Date: ______________________
 
East Buchanan Telephone Cooperative is an Equal Opportunity Provider.