NEMR Authorization for Auto Pay Enroll in Automatic PaymentsPlease Choose One(Required)I DO NOT wish to enroll in Paperless BillingI wish to enroll in Paperless BillingPaperless Billing Email(Required) Please Choose One(Required)I DO NOT wish to enroll in Automatic PaymentsI wish to enroll in Automatic PaymentsCustomer Name(Required) First Last Cell#:(Required)Account Number(Required) 911 Service Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Account (Please select one)(Required)-Checking AccountSavings AccountDebit/Credit CardName(Required) First Last Customer Telephone(Required)Debit/Credit Card Number(Required) Expiration Date(Required) Security Code(Required) Name on Card(Required) First Last Name of Bank(Required) Bank's Telephone Number(Required)Bank's Transit/Routing Number(Required) Customer Bank Account Number(Required) This is to Authorize NEMR Telecom to deduct my monthly bill from the above account on the 10th of each month according to the information provided above. By signing below, you are authorizing NEMR (Northeast Missouri Rural Telephone Company) to deduct from the above debit or credit card information for your monthly bill on the 10th of each month.NEMR will charge a $25 service fee for a rejected automatic payment. It is the customer's responsibility to notify NEMR of any payment changes.Customer's Signature(Required)Today's Date(Required) MM slash DD slash YYYY NEMR is an equal opportunity provider and employer. Reselling of NEMR Products and/or Services is prohibited per our company terms and conditions.