Authroization for Direct Payment

TWO AUTOMATIC PAYMENT OPTIONS AVAILABLE

AUTHORIZATION FOR DIRECT PAYMENT FROM CHECKING OR SAVINGS ACCOUNT

By completing the form below, you authorize regularly scheduled payments on the 10^th of each month to be made from your bank account. At the beginning of each month you will still receive your statement from DTE that shows the amount to be paid from your bank account.

I authorize Dubois Telephone Exchange, Inc. and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you to cancel it.

_______________________________________
    (NAME OF FINANCIAL INSTITUTION)

______________________________
---------------------------------------(BRANCH)

_____________________________________________________________________

(CITY)---------------------------------------------------------------(STATE)

(ZIP CODE)---------------

_______________________________________
    (SIGNATURE)

______________________________
---------------------------------------(DATE)

_______________________________________
    (NAME - PLEASE PRINT)

______________________________
---------------------------------------(TELEPHONE NUMBER)

ACCOUNT No.______________________________ Checking ____ or Savings ____

Financial Institution Routing Number _____________________________________

(between these symbols l: l: on the bottom left of your check)--------

Provide a voided check or a copy of one of your checks.

DIRECT PAYMENT PLAN FROM CREDIT CARD ACCOUNT

By completing the form below, you authorize regularly scheduled payments on the 10^th of each month from your credit card account. At the beginning of each month you will receive your statement from DTE that shows the amount to be paid from your credit card account.

I authorize Dubois Telephone Exchange Inc. to initiate entries to my credit card account. This authority will remain in effect until I notify you to cancel it.

ACCOUNT No. ______________________________ Expiration Date _________

Visa ______ Mastercard ______ Name on Account: ____________________________

_______________________________________
    (SIGNATURE)

______________________________
(PHONE NUMBER)--------------------------(DATE)

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AUTHORIZATION FOR DIRECT PAYMENT FROM CHECKING OR SAVINGS ACCOUNT By completing the form below, you authorize regularly scheduled payments on the 10^th of each month to be made from your bank account. At the beginning of each month you will still receive your statement from DTE that shows the amount to be paid from your bank account.
I authorize Dubois Telephone Exchange, Inc. and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you to cancel it.
_______________________________________ (NAME OF FINANCIAL INSTITUTION)	______________________________ ---------------------------------------(BRANCH)
_____________________________________________________________________
(CITY)---------------------------------------------------------------(STATE)	(ZIP CODE)---------------
_______________________________________ (SIGNATURE)	______________________________ ---------------------------------------(DATE)
_______________________________________ (NAME - PLEASE PRINT)	______________________________ ---------------------------------------(TELEPHONE NUMBER)
ACCOUNT No.______________________________ Checking ____ or Savings ____
Financial Institution Routing Number _____________________________________
(between these symbols l: l: on the bottom left of your check)--------
Provide a voided check or a copy of one of your checks.

DIRECT PAYMENT PLAN FROM CREDIT CARD ACCOUNT
By completing the form below, you authorize regularly scheduled payments on the 10^th of each month from your credit card account. At the beginning of each month you will receive your statement from DTE that shows the amount to be paid from your credit card account.
I authorize Dubois Telephone Exchange Inc. to initiate entries to my credit card account. This authority will remain in effect until I notify you to cancel it.
ACCOUNT No. ______________________________ Expiration Date _________
Visa ______ Mastercard ______ Name on Account: ____________________________
_______________________________________ (SIGNATURE)	______________________________ (PHONE NUMBER)--------------------------(DATE)