Sign-Up and Authorization for Automatic Payment Plan Nodak Account Number Full Name Email Address Phone Number Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Banking Information Account Type - Select -Personal CheckingPersonal SavingsBusiness CheckingBusiness Savings Financial Institution Routing Number Account Number Retype Account Number By checking this box, I authorize Nodak Electric Cooperative, Inc. (Nodak) and my financial institution to initiate recurring withdrawals from my bank account on or near the 25th of each month. I understand that this authority is to remain in effect until Nodak has received notification of its termination and shall be received in such time as to afford Nodak a reasonable opportunity to act on it. Participants will still receive a monthly statement. The amount withdrawn each month will be equivalent to the statement balance. Signee Signature Sign above First Name of Signee Middle Initial of Signee Last Name of Signee Today's Date
