AutoPay Enrollment - Wheat State Technologies

Safe, Secure, and Convenient!

Your phone bill is mailed or e-mailed to you each month. The amount due is deducted automatically from your bank account or charged to your credit card around the 10th of the month. The amount deducted is shown on your bank or credit card statement.

Primary Account Holder Information

Name *

First

Last

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

WST Account Number: *

Payment Information

Choose Payment Method: *

CREDIT CARD AUTOPAY
CHECKING ACCOUNT AUTOPAY

Select One: *

Visa
Mastercard
Discover
American Express

Name as it appears on card: *

Card Number: *

Expiration (MM/YY): *

Card Verification Value (CVV): *

I hereby authorize WST, to initiate CHARGE transactions to my credit card account as indicated.

Bank Name: *

Bank Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Routing Number: *

Account Number: *

Please return a voided check via US Mail to address listed below or to your local WST office:

Wheat State Technologies, PO Box 320, Udall, KS 67146

I hereby authorize WST, to initiate debit entries to my checking account indicated and the depository named above to debit same to such account. This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written notification from me of its termination in such time and manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on my request.

eSignature

PLEASE SIGN BY TYPING YOUR FULL NAME BELOW: *

Date *