NEMR Authorization for Auto Pay

Enroll in Automatic Payments

Please Choose One(Required)

Customer Name(Required)

First Last

Cell#:(Required)

Account Number(Required)

911 Service Address:(Required)

Street Address Address Line 2 City State ZIP Code

Type of Account (Please select one)(Required)

Name(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)