Authorization for Direct Payment Automatic Bill Payment
Company Name:
Dakota Internet Services
(the "Company")
Mailing Address
PO Box 843 Sioux Falls SD 57101
I (we) authorize the Company to initiate variable entries to my (our) account
described below:
Checking Account No.
Savings Account No.
Financial Institution's Name
Financial Institution's Address
Attach a voided check, savings deposit slip OR provide the financial institution's
routing number.
Please Note: The routing number is found between these symbols |:_ _ _ _ _
_ _ _ _|: on the
bottom left of your check or savings deposit slip.
Routing Number:
This authority is to remain in full force and effect until the Company has
received written notification
from me (or either one of us) of its termination in such time and manner as to afford the Company a
reasonable opportunity to
act on it.
Signature: (Optional - For Joint Account)
Full Name: Signature:
Address: Full Name:
Date: Date:
Telephone: Telephone:
Billing Account No.
Attach Voided Check or Savings Deposit Slip Here