Nodak AutoPay

Nodak Electric Cooperative, Inc.
Hidden
Date
MM slash DD slash YYYY
Hidden
Time

: Hours

Minutes

AM/PM
Sign-Up and Authorization for Automatic Payment Plan
Please fill in all fields
Nodak Account Number*
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email
Banking Information
Financial Institution*
Routing #*
Account #*
Account #*
Account Type*
By clicking the submit button below, 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.*
By clicking the submit button below, 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.
I agree
Name of Signee (Person filling out form)*
First (Middle Initial) Last
Signature*
CAPTCHA

Nodak Electric Cooperative, Inc.