Cornerstone Group © 2013
106 West First Street • PO Box 320
Udall, Kansas 67146
620-782-3341 • 800-442-6835
www.wheatstate.com
PRESRT STD
U.S. Postage
PAID
PERMIT NO. 7
Udall, KS
ADDRESS SERVICE REQUESTED
Sign Up For Wheat State’s AutoPay Today!
Enroll in AutoPay today and receive
a coupon good for up to $95 off a
High Speed Internet Gear Kit and
Installation!*
It’s beyond easy.
YourWheat State phone bill
is paid every month–on time–by automatic
withdrawals from your bank account.
Safe, secure…and convenient.
Just return
this Authorization Agreement form and
then sit back and relax.
Got questions?
Call us today at 800-442-6835.
*Coupon must be used within 30 days of enrollment in
AutoPay. This coupon cannot be combined with any other
special offers.
Here’s how it works:
• Your phone bill is mailed to you each month.
• The amount due is deducted automatically from your bank account
or charged to your credit card around the 10th of the month.
• The amount deducted is shown on your bank or credit card statement.
AUTHORIZATION AGREEMENT
Name
Address
Phone Number (620)
Wheat State Account #
Choose one option:
Checking Account Auto Debit
I (we) hereby authorize Wheat State Telephone, hereinafter called COMPANY, to initiate debit entries to my
(our) checking account indicated and the depository named below, herein called DEPOSITORY, to debit same
to such account.
Your Financial Institution Name
Date
Routing Number
Account Number
Address
City/State/Zip
The authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written
notification from me (or either of us) of its termination in such time and manner as to afford COMPANY
and DEPOSITORY a reasonable opportunity to act on my request.
PLEASE ATTACH A VOIDED CHECK
REQUIRED FOR VERIFICATION.
Signature
Credit Card Auto Charge
Choose one:
VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Credit Card #
Expiration Date
Signature
Please return completed form to:
Wheat State Telephone • P.O. Box 320 • Udall, Kansas 67146
