117 East First
PO Box 306
Monticello, IA 52310
Automatic checking withdrawal authorization.
Please print out, fill out, and return this form to Netconnect. If you have any questions or just need help
completing the form, call 319-465-6336 for assistance.
First Name Initial Last Name
Address City State Zip Code
Phone Number E-mail address
Tell us about the checking account from which your payment is to be deducted
Bank Name City State
RTN:(the 9 digits preceding the colon on the bottom of your check)_________________
Checking account number (all digits following the colon)__________________________
$_________ on twenty fifth (25th) day of the month starting __________25___ Month
We Need your signature
Please date with TODAYS DATE__________________________________________
By signing above I am authorizing Netconnect to initiate debit entries to my account. This authorization shall remain in full force and effect until Netconnect has received written or emailed notification from me to terminate this Authorization in such time and such manner as to afford Netconnect and my bank 30 days to act on it. In the event I initiate a chargeback or reversal of charges through my bank without contacting Netconnect 30 days in advance, I agree to pay Netconnect a $100 chargeback fee. Such debits shall initially be
made from the account described above.