Bank Draft Authorization Form

Please send a copy of a voided check for our record and for verification purposes along with this form to:

Logan Telephone Co-Op Inc.
PO Box 97
Auburn, KY 42206

Name as shown on bank records:_____________________________________________

I hereby authorize my telephone bills to be paid by my bank:

DEPOSITOR'S SIGNATURE:___________________________  DATE:____________

TELEPHONE NUMBER:____________  BILLING NUMBER:___________________

It will not be necessary for Logan Telephone Cooperative or anyone employed by it to sign such drafts or checks, and I agree that your rights in respect to each such draft or check shall be the same if issued and signed personally by me. I further agree that you shall be under no obligation to furnish me with any special advice or notice in writing or otherwise or the presentment or payment of any such draft or check or the charging of the same to my account.

This authorization is to remain in effect until revoked by me in writing, and until you actually receive such notice. I agree that you shall be fully protected in honoring any such draft or check.