Name(Required) First Last HiddenAccount Number OLDAccount Number(Required) Primary Phone Number(Required)Email for Communication(Required) Service Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Deposit Amount Waived(Required)Reason Being Waived(Required) EFT (automatic payment) PREPAY Disclaimer(Required) If at any time there are 2 NSFs (insufficient funds) or declined transactions on the account or the automatic payment is deleted off the account, the deposit will be added to the account and become due immediately. Your account will be marked for disconnect and disconnected on our next disconnect day if it is not paid. No payment arrangement or any other extensions will be allowed on deposit amounts. I have read this disclaimerTerms and Conditions(Required) I understand it is my responsibility to maintain my EFT (automatic pay) status as active using my checking account information in order to continue service with no deposit and to avoid disconnection. I have read, understand and agree with the terms and conditions of signing up for automatic payment in order to waive my deposit. AcceptElectronic Signature (Full Name)(Required) CommentsThis field is for validation purposes and should be left unchanged.
