Authorization Agreement for Automated Payments

 

I (we) hereby authorize EAST BUCHANAN TELEPHONE COOPERATIVE to initiate debit entries to my (our) Checking Savings account indicated below and the bank named below to debit same to such account.

 

Bank Name: _________________________________________________________________

Branch:        _______________________

City: ___________________________________
Account #: ________________________ Routing #: ______________________________
 
Primary Name: _______________________________________________________________
Joint Name: _________________________________________________________________

 

Accounts to be debited:

 

_______________________________________

  _______________________________________
  _______________________________________
Signature: ______________________________________ Date: ______________________
 

 

East Buchanan Telephone Cooperative is an Equal Opportunity Provider.