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2. The City of Bullard will draft your bank account monthly upon submission of this form. I understand that the first draft will begin with the second billing after timely receipt of this form. I hereby authorize the City of Bullard to withdraw a draft from my bank account listed below monthly for services rendered, and if necessary, initiate for any transaction debited or credited in any error. This authority will remain in effect until the City of Bullard is notified by me in writing, to cancel and until the City of Bullard has reasonable time to make that change. I agree that the City of Bullard will charge an NSF fee of $30.00 and other possible penalties. Initiation or cancellation of this service may take up to 60 days. Until I receive a bill marked 'PAID BY DRAFT' I am responsible for payment on my own initiative. All drafts will be processed for payment on the 17th of each month.

4. Utility Account Information
6. Name(s) on Account*
7. Service Address*
9. Account Number*
10. Phone Number*
12. Mailing Address
    If different from above.
14. Bank Account Information
16. Name(s) on Account*
17. Bank Name*
19. Routing Number*
20. Account Number*
22. Account Type

    1. Checking

    1. Savings
24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Customer Signature
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field