Credit Card

Member Auto Bill Authorization Form

Member Name: ______________________________________________

Home Address: ______________________________________________

______________________________________________

RECC Account No. ______________________________________________

Credit Card Statement Sent to Above Address: ( ) Yes ( ) No

Home Telephone: ______________________________________________

Visa _______ Master Card________

Credit Card Account Number: _______ - ________ - _______ - _______

Expiration Date: Month: ___ ___ Year: ___ ___

What Month Do You Want to Start: ___________________________________

I agree to authorize my Cooperative utility to automatically charge my monthly electric bill to my Visa/MasterCard credit card. I understand that this Auto Bill program does not include typical credit card chargeback rights and procedures. I will contact the Cooperative directly concerning billing disputes.

Signature: _____________________________________________________

Print Name: _____________________________________________________

Date: ___________________

PRINT THIS PAGE, FILL IN THE FORM AND MAIL TO: RECC, PO Box 19, Auburn, IL 62615