EZ PAY AUTHORIZATION FORM

Thank you for choosing the LOCL.net EZ PAY payment option. The bank requires that we have a signature on file so please complete the following form, sign it and fax to 260-665-1993 or return it to LOCL.net, Inc. , P.O. Box 1100, Angola, IN 46703 at your earliest convenience.

Name on the Account_________________________ Bank Routing #:________________

Bank Name_________________________________ Account #_____________________

Account Type: Checking [ ] Savings [ ]

I, the undersigned, give permission to LOCL.net to automatically withdraw from the bank account mentioned above, my monthly payment in the amount of __________ as payment for my Internet account number _____________ provided by LOCL.net, Inc. The deduction will be made on the 3rd of each month for that month’s service.

I understand that I must inform LOCL.net of any intention to close my account or change my payment option no later than the 25th of the month to prevent the automatic deduction from being taken from my account the following 3rd.

Dated________________________________

Signature_____________________________

Printed Name__________________________

Phone Number_________________________ LOCL.net Email_______________@locl.net

Download an Authorization Form word document here