EmailMeForm
Application for EFT Automatic Payment
Blanca Networks
129 Santa Fe Ave
Alamosa, CO 81101
Please complete and submit the application below for Electronic Funds Transfer.
All fields are secure.
Account Information
Name
*
First
Last
Cell Phone Number
*
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Home Phone Number
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Email
*
Automatic Payment
Payment Information
*
I would like to add my payment information for $5.00 off my first month of service
Promotion valid for a limited time only. Terms & conditions may apply.
Name of Bank
*
Name on Account
*
Bank Routing Number
*
Bank Account Number
*
Blanca Networks will automatically charge this bank account number for the amount of your bill between the 1st and the 10th day of every month.
Special Notes
Legal Information
Paperless Billing
*
I would like to have my monthly bill emailed to me
I would prefer to have my monthly bill mailed to me
Get your full monthly bill right to your email inbox instead of in the mail.
Information Verification
*
I swear, under penalty of perjury, that all the above information is correct and accurate
By checking this box, I acknowledge that the information provided in this application is factual and true.