Sign-Up and Authorization for Automatic Payment Plan Nodak Account Number Full Name Email Address Phone Number Address Address Address 2 City/Town State/Province North DakotaAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Banking Information Account Type - Select -Personal CheckingPersonal SavingsBusiness CheckingBusiness Savings Financial Institution Routing Number Account Number Account Number By checking this box, I authorize Nodak Electric Cooperative, Inc. (Nodak) and my financial institution to initiate recurring withdrawals from my bank account on or near the 25th of each month. I understand that this authority is to remain in effect until Nodak has received notification of its termination and shall be received in such time as to afford Nodak a reasonable opportunity to act on it. Participants will still receive a monthly statement. Signee Signature Sign above First Name of Signee Middle Initial of Signee Last Name of Signee
