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2. Select One:*

   1. Credit Card
   2. Bank Draft
3. Name on Account*
5. Address*
6. City*
7. State*
9. Phone Number*
10. Email Address*
12. Financial Institution Name:
13. ABA Routing Number:
15. Bank Account Number:
16. Check One:

    1. Savings
    2. Checking
18. Card Number:
19. Expiration Date:
20. CVC:

22. By Completing this form, I am authorizing the Town of Maysville to draw monthly drafts against my designated card of bank account for the total amount owed on my account. I understand that I may discontinue my participation by contacting the Tow nof Maysville. I understand the Town of Maysville reserves the right to discontinue my participation at any time.

    
    

24. Account Holder's Signature*
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field