Auto Pay Application (Online Check)
Auto Pay is a free service that makes paying your
bill easier. Just print this page, fill out the form completely, include a voided
check or deposit slip (with a nine-digit routing number) and mail it
to us with your next bill.
PC Brokers (Boulder Group)
1911 11th st
Suite #104
Boulder, CO 80302
Personal/Business Information (please print)
Name / Business Name (as it appears on your bill)
_____________________________________________________________________________________
Domain Name = Account # (as it appears in
the lower left section of your bill) ____________________________ . ____
Address (as it appears on your bill)_
__________________________________________________________________________________
City___________________________________________________
State _ __________________ZIP_ ____________________________
Home phone
_______________________________________ Work
phone___________________________________________________
Financial Information (please print)
Name of Bank or Financial Institution_
_____________________________________________________________________________
Please withdraw payments directly from
my:
Checking account
(include voided check)
Savings account
(include voided savings deposit slip)
Bank or Financial Institution Account
Number_
______________________________________________________________________
Routing (ABA) Number*_
________________________________________________________________________________________
I authorize PC Brokers (Boulder Group) to initiate
transfers from my designated account to make monthly payments on my account. This authority will remain in effect until I notify PC Brokers (Boulder Group).
Authorized
signature____________________________________________________________________________________________
Signature must match name on the
account. Application forms without a valid signature cannot be
processed.
*The Routing (ABA) Number is a
nine-digit number located in the bottom left-hand corner of your
check and is unique to your financial institution.
PLEASE KEEP A COPY OF THIS
AUTHORIZATION FOR YOUR RECORDS.