Auto Pay Application (Online Credit/Debit)
Auto Pay is a free service that makes paying your bill easier.
Just print this page, fill out the form completely, 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: _______________________________________
Credit/Debit Card information:
Please withdraw payments directly from my:
Credit/Debit Card: (please circle one of the following)
Visa Master Card American Express Discover Card
Card #
Expiration Date:
CVV code (back of card):
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.
PLEASE KEEP A COPY OF THIS
AUTHORIZATION FOR YOUR RECORDS.