Bank Draft Authorization

Name

This field is for validation purposes and should be left unchanged.

Until further notice, you are requested and herby authorized to draw on my checking account at the listed bank to cover electric billing on the following accounts:

NTEPA Account Number(Required)

Phone(Required)

Bank Name(Required)

Bank Routing Number(Required)

Account Number(Required)

Account Name(Required)

Services to Draft(Required)

Which services would you like to be drafted on your bank account?

Electric

Fiber

Both Electric & Fiber

Voided Check(Required)

Please attach a photo of a "voided" check.

Max. file size: 100 MB.

Additional Details(Required)

Please provide the account number(s) or service address(s) that you would like to enroll in bank draft. If you would also like us to draft your fiber account, then please specify this below. Please note that these accounts must be associated with you in order for the request to be approved.

Member Signature (Full Name)(Required)