Request for Automatic Bank Payment Plan PhoneThis field is for validation purposes and should be left unchanged.Name(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Which accounts would you like to setup on Auto Bank Draft?(Required)Please have your account number ready. Electric Account Internet Account Telephone Account Electric Account Number(Required)Internet Account Number(Required)Telephone Account Number(Required)Bank Name(Required)Account Type(Required) Checking Savings Bank Account Number(Required)Bank Routing Number(Required)Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If available, please attach a voided checkPlease upload a clear photo or PDF of a voided check. We use this to instantly verify your routing and account numbers to prevent payment delays.Max. file size: 250 MB. Agreement for Automatic Bank PaymentsI understand that beginning next month and continuing each month thereafter, the amount of my electric and/or telecommunication service billing will be deducted from my bank account. I authorize Canadian Valley Electric Cooperative, Inc. (CVEC) and/or CVEC Fiber, LLC (CVF) to initiate monthly deductions for payment of my electric and/or telecommunication bill and for the financial institution specified by me to pay the amount from my checking or savings account 10 days after the bill is mailed. This authority shall remain in effect until revoked by me in writing. In addition, I have the right to stop payment for a charge up to 10 days after being billed by CVEC or CVF. I understand that either CVEC, CVF and/or my financial institution reserve the right to terminate this payment plan or my participation therein.Authorization & Agreement(Required)I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature. I agree to the privacy policy.Member Electronic Signature (Full Name)(Required)
