ROGERS WATER UTILITIES
601 South 2nd Street

P.O. Box 338

Rogers, Arkansas 72756
Phone (479) 621-1142
Fax (479) 621-1146

ACCOUNT INFORMATION

Account Name:____________________________________________________
Customer Account Number:__________________________________________
Street Address:____________________________________________________
Telephone Number:_________________________________________________

BANKING INFORMATION (Checking Account)

Select the Account Type:

Checking

Savings

Bank Name:______________________________________________________
Account Number:__________________________________________________
Transit Number:___________________________________________________

BANKING INFORMATION (Credit/Debit Card)

Select the Card Type:

MasterCard

Visa

Discover

Card Number:_____________________________________________________
Expiration Date::___________________________________________________
Billing Phone (Required)::____________________________________________
Email Address (Required)::___________________________________________

Start With Bill Due:__________________

I authorize Rogers Water Utilities to charge (draft) the payment of my monthly bill and the bank listed above to charge the drafts to my account. I understand that this authorization will be in effect until I notify Rogers Water Utilities and my bank in writing that I no longer desire this service. I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account.

I have the right to stop payment by notifying my bank before the account is charged. If an erroneous draft entry is charged against my account, I have the right to have the amount of the entry credited to my account.

I understand that Rogers Water Utilities may impose a late payment and delinquent fees in the event the debit entry is not paid by the bank for a valid reason. The electronic drafts can be cancelled at any time by either party.

Signature:__________________________________     Date:_____________

IMPORTANT: Did you enclose a voided check or a photocopy for Checking Account Draft?