Bank Draft Form

(You must print off this form, sign it  and take it to the PLWC office or send it in with your payment.)
(A voided check is also preferred.)

Paragould Light Water and Cable
Authorization Agreement for Pre-Arranged Payments (Debits)


I (We) hereby authorize Paragould Light Water and Cable to initiate charge entries to my (our) checking account indicated below and the bank/savings institution named below, to charge the same to such account.

PLWC Account Number ________________________________________________________

Name ______________________________________________________________________

Address ____________________________________________________________________

Bank Name __________________________________________________________________

Bank Transit Number _________________________________________________________

Bank Account Number _________________________________________________________

Signature(s) __________________________________________ Date __________________