AutoPay Written Form

Auto-Pay Enrollment Authorization Form
Simplify your life and set up your account on Auto-Pay to have your payment drafted automatically each month
without having to worry about writing a check or licking a stamp.
Customer Information
Name:
Account Number:
Service Street Address:
Telephone Number:
City:
State:
Zip:
Select between credit card or bank draft and complete the appropriate section below:
Bank Draft
Financial Institution Name:
Name of Accountholder:
Routing #:
Account #:
I hereby authorize Beyond Power to transact a recurring debit on the account designated above in the amount & on the due date designated on my monthly invoice. I agree that
ACH transactions authorized here in shall comply with all applicable U.S. law, including NACHA ACH Rules.
Credit Card
Type of Card (Check One):
MasterCard
Visa
Discover
Name on Card:
Credit Card #:
Expiration Date:
/
Billing Street Address:
City:
State:
Zip:
I hereby authorize Beyond Power to charge my account for the account designated above in the amount & on the due date
designated on my monthly invoice. Beyond Power reserves the right to debit or credit the above indicated account in the event of
prior balances, errors, omissions or corrections. If a transaction is returned, Beyond Power may transact a separate debit to collect
any related fees. You may terminate this recurring authorization for any reason by writing 2150 Town Square Place #380, Sugar
Land, TX 77479, e-mailing [email protected] or telephoning (888)-316-4607 Beyond Power during our
normal business hours, at least 10 business days before the next scheduled debit.
I have read, understand and approve this Automatic Payment Authorization:
Printed Name:
Signature:_______________________________
Date:
Return the completed form via fax to (888) 316-4912 OR
Mail to: 2150 Town Square Pl., Ste. 380, Sugar Land, TX 77479