Auto-Pay Sign up Form

Sign up for Auto-Pay today!
Westmore Fuel Account #:
Name On Westmore Fuel Account:
Daytime phone#:
email address:
Remarks or Reference:
CREDIT CARD AUTHORIZATION:
Name on Credit Card:
Billing Address of Credit Card:
Credit Card number (without spaces):
Credit Card Expiration Date:
Master Card? Yes
No
Visa Card? Yes
No
Discover Card? Yes
No
I authorize Westmore Fuel Co. Inc. to automatically apply charges for my oil heating bills/ service bills at their regularly scheduled billing intervals to the charge card account indicated above. Yes
No
ELECTRONIC FUNDS TRANSFER AUTHORIZATION:
You can also pay your bills by deducting directly from your checking or savings acocunt. I want to use Echeck: Yes
No
Name on Bank Account:
Bank ABA #:
Bank Account:

As a duly authorized check signer on the financial institution account listed above. I authorize Westmore Fuel Co. Inc. to perform scheduled or periodic electronic funds transfer debits and or/credits from my account for payments due or when applicable, apply electronic funds transfer credits to the same. This applies to check by phone payments as well as any other electronic payment.

Furthermore, if any such electronic debit(s) should be returned by my financial institution as Non-Sufficient Funds (NSF), I authorize, Westmore Fuel Co. Inc., to collect a returned item fee of $40.00 per item by electronic debit from my account.

For accounting purposes, all electric debits will be reflected in the monthly bank statement that corresponds with the financial institution account listed above.

I authorize Westmore Fuel Co. Inc. to automatically apply charges for my oil heating bills/ service bills at their regularly scheduled billing intervals to the bank account indicated above according to the terms above. Yes
No
SET UP A BUDGET PLAN:
I would like to set up a budget plan (spreads your fuel and service costs over 11 equal monthly payments, RECOMMENDED! ) Yes
No