AUTHORIZATION FOR AUTOMATIC PAYMENT

This is the check-free, mail-free, hassle-free way to pay your bill.

Simply print this form, complete the entries and mail to our office at

West Central Sanitation

PO Box 796

Willmar,  MN  56201  
Do not submit this form by e-mail as an authorized signature is required.

You will receive a statement as usual showing payments received and current charges.  However, you won't need to write a check, pay for a stamp and mail your payment to us.  Instead, your payment will be automatically deducted on the payment due date from your checking or savings account.

I hereby authorize West Central Sanitation to initiate debit entries to my checking or savings account.  This will remain in force until written notice of termination is received in such time and manner to afford a reasonable opportunity to act on it.

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BANK INFORMATION

Name of Bank
Bank Address
Bank Routing Number
Bank Account Number
Checking               Savings

CUSTOMER INFORMATION

First Name
Last Name
W.C.S. Account #
Address
City
State
Zip Code
Date
Signature
West Central Sanitation
Copyright © 2003 All rights reserved.
Revised: May 21, 2007