print this page


            Southeastern Indiana REMC               
            Reoccurring Credit Card Payment Authorization Form      

Please complete this form and send to:
Southeastern Indiana REMC
712 S Buckeye St.
Osgood, IN 47037

Customer Information

 		 Your Personal Credit Card Information
Customer Name ( as it appears on bill )

______________________________________
Service Address

______________________________________
City                        State                       Zip

_________________________________
Telephone		 Name as it appears on the Card.

________________________________________
 Account Number: ( Credit Card )

_________________________________________
Expiration Date

 _________________________________________

_______________________________________
 Southeastern Indiana REMC Account Number
Card Type  Master Card______    Visa_______
*Master Card and Visa only

_______________________________
Signature                                            Date
   
                                           

_______________________________________

I authorize Southeastern Indiana REMC to debit the
designated credit card to pay my total bill.  I
understand that I control my payments, and if at
any time I decide to discontinue this payment service,
I will notify Southeastern Indiana REMC in such time
and manner so as to afford the company reasonable
opportunity to act on it.  Discontinuance of this
payment service shall not affect any amounts owed
by me to the company. 

 
Please notify Southeastern Indiana REMC of any changes to your credit card account.