Bank Transfer Authorization Form

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Information About You

Your Name

First

Last

Customer Account Number

Your Email

Your Phone Number

Today's Date

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Your Billing Prefences and Information

I agree to these terms

I authorize Mason's Propane Service LLC to electronically debit my bank account according to the terms outlined below. I acknowledge that electronic debits against my account must comply with United States law. Mason's Propane Service is not responsible for any overdrafts or overdraft fees caused by the automatic draft.

Terms of billing

One Time Payment

Monthly Payment with my amount specified

Monthly Payment with amount due and accordingly thereafter

Amount due immediately when billed

Run amount owed on the due date

One time payment on

for the amount of $

Starting on

The date you would like to start

And on the day of each month

What day of each month would you like to be billed?

Of each month through

Choose when to stop payments

For the amount of $

Starting on

Amount due immediately when billed

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Customer bank account information

This information will be encrypted

Account Type

Checking

Savings

Consumer

Business

Routing Number

Account Number

I agree to these terms

This payment authorization is to remain in effect until I notify Mason's Propane Service LLC., of its cancellation by giving written notice in enough time for the business and receiving financial institution to have a reasonable opportunity to act on it.