Thank you for agreeing to pay your bill using Automatic Payment. Electronic payment is a time saver for us and we trust you will find the convenience equally as satisfying.
Banking rules require that you give your approval to pay your bill in this way. The approval is active until you notify us that you want to stop using Automatic Payment.
Automatic Payment is safe, efficient, and consumer friendly. Banking law protects consumers from ever having to worry about someone taking money from their account using Automatic Payment in an unauthorized manner.
PREFER TO FILL THIS AUTOMATIC BANK DEDUCTION AUTHORIZATION OUT BY HAND? CLICK HERE FOR A PDF TO PRINT/SEND VIA FAX OR MAIL
1. Please fill out this automatic bank deduction authorization in full. NOTE: *Required Field. 2. Read the Authorize Transactions & Conditions then click the agree check box. This will then turn on the SUBMIT button. 3. Click the SUBMIT button on the bottom to submit the final form. NOTE: You will be sent to a Thank You page when your application is successfully submitted.
Residential Commercial
*Company Name:
*first name:
*last name:
*email:
*address 1:
address 2:
*city :
*state: APO (AA) Alberta APO (AE) ALASKA ALABAMA APO (AP) ARKANSAS American Samoa ARIZONA British Columbia CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA Micronesia FPO (FP) GEORGIA Guam HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANNA MASSACHUSETTS Manitoba MARYLAND MAINE Marshall Islands MICHIGAN MINNESOTA MISSOURI Northern Mariana Islands MISSISSIPPI MONTANA New Brunswick NORTH CAROLINA NORTH DAKOTA NEBRASKA NewFoundland NEW HAMPSHIRE NEW JERSEY NEW MEXICO Nova Scotia Northwest Territories Nunivat NEVADA NEW YORK OHIO OKLAHOMA Ontario OREGON PENNSYLVANIA Prince Edward Island Quebec Puerto Rico Palau RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA Saskatchewan TENNESSEE TEXAS UTAH VIRGINIA Virgin Islands VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Yukon
*zip:
country:
acct holder name & address same as applicant?:
*First Name:
*Last Name:
*Addr1:
Addr2:
*City:
*State: APO (AA) Alberta APO (AE) ALASKA ALABAMA APO (AP) ARKANSAS American Samoa ARIZONA British Columbia CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA Micronesia FPO (FP) GEORGIA Guam HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANNA MASSACHUSETTS Manitoba MARYLAND MAINE Marshall Islands MICHIGAN MINNESOTA MISSOURI Northern Mariana Islands MISSISSIPPI MONTANA New Brunswick NORTH CAROLINA NORTH DAKOTA NEBRASKA NewFoundland NEW HAMPSHIRE NEW JERSEY NEW MEXICO Nova Scotia Northwest Territories Nunivat NEVADA NEW YORK OHIO OKLAHOMA Ontario OREGON PENNSYLVANIA Prince Edward Island Quebec Puerto Rico Palau RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA Saskatchewan TENNESSEE TEXAS UTAH VIRGINIA Virgin Islands VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Yukon
*Zip:
Country:
*phone:
*Bank Name:
*Bank Addr1:
Bank Addr2:
*Bank City:
*Bank State: APO (AA) Alberta APO (AE) ALASKA ALABAMA APO (AP) ARKANSAS American Samoa ARIZONA British Columbia CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA Micronesia FPO (FP) GEORGIA Guam HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANNA MASSACHUSETTS Manitoba MARYLAND MAINE Marshall Islands MICHIGAN MINNESOTA MISSOURI Northern Mariana Islands MISSISSIPPI MONTANA New Brunswick NORTH CAROLINA NORTH DAKOTA NEBRASKA NewFoundland NEW HAMPSHIRE NEW JERSEY NEW MEXICO Nova Scotia Northwest Territories Nunivat NEVADA NEW YORK OHIO OKLAHOMA Ontario OREGON PENNSYLVANIA Prince Edward Island Quebec Puerto Rico Palau RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA Saskatchewan TENNESSEE TEXAS UTAH VIRGINIA Virgin Islands VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Yukon
*Bank Zip:
*Account Type: Checking Savings
*Transit/ABA Number:
*Account Number:
*Authorized Charges: All Charges Budget Plan Propane Deliveries Only Service Invoices Only
AUTHORIZE TRANSACTIONS & CONDITIONS: I/we hereby authorize George Propane, Inc. to initiate entries to my checking or savings account at the financial institution listed above. In the event a transaction is returned unpaid for any reason, I/we also authorize the company to initiate a $35.00 returned item fee. George Propane, Inc. is not responsible for overdrawn account balances or overdraft fees charged by your financial institution. This authority will remain in effect until five (5) days after I/we provide written notice to cancel it.
