NetWest AutoPay - Automatic Payment Authorization Form

Checking Account
(Attach a voided check)

Credit Card
Exp. Date _____ / ______

Account Number : ______________________________________

Amount: $________________

Beginning: _____/_____/_________
Company Name: NetWest Online Inc.

TERMS AND CONDITIONS
(please read carefully)

· Each month, the account I have indicated above will be charged automatically for the amount shown above.

· It is my responsibility to ensure that there are enough funds available in the account designated to cover the amount due shown above. If a charge to my account is rejected because of insufficient funds, CP Automation Inc. will charge my account a return item processing fee of $25.00.

· This authorization to charge my account shall be the same as if I had personally signed the check.

· I understand that a record of my payments will be included in my bank/credit card statement. I have the right to have any erroneous entry corrected. This must be done within 45 days after the debit was made.

· I may revoke this authorization by providing 30 days written notice, by certified mail to: NetWest Online Inc. , 5000 E. University Suite 11, Odessa Texas 79762.

Signature: __________________________________________

Print Name: _________________________________________

Date: ______/______/__________

Phone Number: (______) ______________________

Please print this form and mail to:
NetWest Online
5000 E. University Suite 11
Odessa, Texas 79762
(remember to attach a voided check if applicable)