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Checking/Savings Online Payment Authorization Form

Customer Information
Date:
Company Name:
Contact Name:
Address:
City:
State:
Zip:
Phone:
Business Phone:
Email:
Billing Information
Check Routing #:
Checking Account #:
Check #:


  Set up automatic monthly payments (Required for Residential Services)
  One-time only payment
I , authorize UTMI.net
           (name as it appears on card)
to automatically withdraw $ from my personal/business checking or savings account to pay my phone bill on cynergycomm.net account number#

 
 
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