EmailMe Form - Application for EFT Automatic Payment

Name *

First Last

Cell Phone Number *

### - ### - ####

Home Phone Number *

### - ### - ####

Email *

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

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.