bright.net north, Inc.
720 N Perry
Napoleon OH 43545
PH. 1-800-633-6245 /
FAX 419-717-5603
Automated Bill Payment Enrollment for your bright.net service
Name (as shown on your check or credit card) ________________________________________
Address ______________________________________________________________________
City/State/Zip __________________________________________________________________
Daytime Phone # _______________________________________________________________
Login ID ______________________________________________________________________
Please deduct my Automated Bill Payment from my account:
Checking R/T # ______________________________________________
Name of Bank ______________________________________________
** Please enclose a signed voided check or checking deposit slip with this form.
Credit Card type: Visa Mastercard
Account Number _____________________________________
Expiration Date ______________________________________ / CVV2 ______
I authorize bright.net North to deduct my payment from the account listed above. I understand that if I decide to discontinue this payment plan I will notify in writing bright.net North at the following address:
bright.net North Inc
720 N Perry St
Napoleon, OH 43545
Signature ____________________________________________________ Date ____________
The money due will be withdrawn from your account on the 25th of the month.