Kansas Independent Telecommunications, LLC
DBA Carroll’s Web

I hereby authorize Kansas Independent Telecommunications, LLC, hereinafter referred to as Carroll’s Web, to initiate debit entries to my Checking____ Savings_____ account (check one) indicated below at the financial institution named below.

Monthly charges will be electronically drafted on your scheduled date. If your draft is returned to us due to non sufficient funds, we will run the draft one more time with a $3 handling fee. If it is returned a second time, your account will be disabled and charged a $30.00 returned check fee.

Financial Institution Data:

Bank

Name:___________________________________________ Branch:______________________________

City:________________ State:______ Zip:_________________

Routing/Transit/Aba Number:_______________________
Account Number:__________________________________

Note: Please attach a voided check to ensure accuracy of information.

This authority is to remain in full force and effect until Carroll’s Web has received written notification from me of its termination in such time and in such manner as to afford Carroll’s Web a reasonable opportunity to act on it.

Printed Name:__________________________________ Date:______________________________

Account Owner Signature:_________________________________________________

-------------------------------------------------Please Detach and Save for Cancellation--------------------------------------

Cancellation

I request that the ACH credit noted above be cancelled effective:______________________________.

Signature of Account Owner:________________________________________________

* Cancellation must be received at least 30 days prior to the next scheduled payment date. Signature required for cancellation.

Please return this form to:
Carroll’s Web
P.O. Box 2060
Salina KS 67402-2060