Automatic Payment Authorization | Capital Electric Cooperative, Inc

HOW TO SIGN UP

This form is to sign up for autopay only
Complete and submit this form
Automatic payments will typically begin with the next billing statement, but may take up to four (4) weeks
The selected method of payment will be drafted for the amount due and will occur on the due date each month
Contact our office at (701) 223-1513 with any questions
If you move addresses within the Capital Electric territory, this automatic payment will transfer on to your new service unless the cooperative is notified otherwise.

Capital Electric Account Number(s):

Capital Electric Account Name:

Service Address

Primary Phone:

Secondary Phone:

E-mail Address

Will you be signing up with a Checking/Savings Account or a Credit/Debit Card?

Bank Authorization

Checking Information

Name of Financial Institution

"Name of Individual(s) Listed on Bank Account"

Checking Routing #

Checking Routing # (Verify)

Checking Account #

Checking Account # (Verify)

Savings Information

Name of Financial Institution

"Name of Individual(s) Listed on Bank Account"

Savings Routing #

Savings Routing # (Verify)

Savings Account #

Savings Account # (Verify)

Card Authorization

Card Information (American Express)

Cardholder's Name (as shown on card)

Cardholders Address

Cardholder's City

Cardholder's State

Cardholder's Zip Code

Credit Card Number

Credit Card Number (Verify)

Exp. Month

Exp. Year

Card Authorization

Card Information (Visa/Master/Discover)

Cardholder's Name (as shown on card)

Cardholder's Address

Cardholder's City

Cardholder's State

Cardholder's Zip Code

Credit Card Number

Credit Card Number (Verify)

Exp. Month

Exp. Year

Applicant Signature

Sign above

Today's Date

Payment Section

Bank Authorization

Card Authorization

Card Authorization