Bank Draft Authorization Form

We have chosen the convenience of "pre-authorized checks" as the method of purchasing Internet service from Internet Pathway. We understand that the amount shown below will be drafted from our checking account and that this transaction will appear on our monthly bank statement.

Please note that all records are strictly confidential. Should you decide to discontinue service, please email us at billing@netpathway.com, or call us at 601-776-3355 or 601-683-7915.

To enroll in our bank draft service, please print and complete this form and attach your voided check.

Authorization, Terms and Conditions: By mailing the completed enrollment form, you authorize Internet Pathway to automatically debit your checking account each month for the amount of your Internet bill. Your payments will be debited from your checking account on the date indicated on your Internet bill. This authorization applies to the account shown on the enclosed form and any future account you may designate by calling Internet Pathway. You also understand that you will receive an email statement each month and no longer receive a postal statement. Your participation is subject to Internet Pathway's approval. Internet Pathway has the right to terminate this payment option at any time. You may discontinue this service at any time with 30 days advance written notice to Internet Pathway. If for any reason the draft is returned, you will be required to pay the amount of the bank draft transaction plus a return fee of $15.00 in cash or money order. All charges, terms, and conditions are subject to change. Any adjustments to your account balance received up to five business days before your payment date may be reflected in your direct debit amount. You understand and agree that Internet Pathway is not liable for erroneous bills or incorrect debits to your account, except should an error in the bill occur. Internet Pathway is not responsible for any bank fees as a result of this program. Internet Pathway reserves "the right to terminate" option if your bank returns a payment. This agreement does not alter in any way the Customer Access Terms and Conditions for Network Services or separately negotiated contract.

Bank Draft Authorization Form
Internet Pathway is authorized to draft the account shown below for my $___________ monthly payment beginning (month)_____________, 2008. The transaction date of this draft will be the first day of each month.

Printed Account Name _____________________________________

Account Number ___________

Signature ________________________________________________

Write "VOID" across a check from the account to be drafted and attach it here.

 

 

 

 

 

 

Click File | Print to print this form.
Fax this completed form to 601-776-2314
Or mail it to Internet Pathway, P. O. Box 777, Quitman, MS 39355

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