Authorization Agreement for Automated Credit Card Payments
| I (we) hereby authorize EAST BUCHANAN TELEPHONE COOPERATIVE to initiate debit entries to my (our) VISA MASTERCARD DISCOVERY account indicated below. | |
| Card #: _________________________________________ | Expires: ______________________ |
| Primary Name: __________________________________________________________________ | |
| Joint Name: ________________________________________________________________ | |
| Accounts to be debited: | _________________________ |
| _________________________ | |
| _________________________ | |
| Credit Card Payment Date: ____________________________________________________ | |
| Signature: ______________________________________ Date: ______________________ | |
East Buchanan Telephone Cooperative is an Equal Opportunity Provider. |
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