AUTHORIZATION AGREEMENT FOR BANK OR CREDIT CARD DEBITING

If you would like to enjoy the convenience of automatic billing, simply complete either the Bank or Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically debit your bank account or credit card the appropriate amount indicated on your monthly bill on the due date. You may cancel this automatic billing authorization at any time through written notification.  Please allow up to 30 days for processing enrollment forms and cancellation notices.






                       Customer Name: 
                                       email: 
            Utility Account Number: 
                        Phone Number: 
         Alternate Phone Number: 
        Month to Begin Payments: 

  SECTION A - CREDIT CARD INFORMATION

                     Credit Card Type: 
                Credit Card Number: 
                    Expiration Month:  
                       Expiration Year:  
              Name on Credit Card: 
                 CSI (Security Code): 

  SECTION B - BANK INFORMATION

                 Bank Account Type: 
                             Bank Name: 
             Bank Routing Number: 
            Bank Account Number: 

  I (we) hereby authorize Quadvest, LP or Ranch Utilities, L.P. to initiate debit entries to my (our) checking or credit card listed below for the appropriate monthly amount due for my (our) utility service on the due date.  I also understand that this automatic billing will continue until written cancellation is provided.  I also understand that due dates are pre-set.  I agree with all conditions.