East Buchanan Telephone Cooperative

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.