KVNet eCheck

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eCheck Application Form (must provide a voided check to be eligible)

Name (Please print name as shown on statement)

Street Address (as shown on check)

City or Town Zip

Home Phone Business Phone (optional)

KVNet Account Number (optional)

Name of Financial Institution or Branch

I hereby authorize my Internet service bills to be paid by KVNet Automatic Draft Services.*

Signature Date

Please include a copy of a voided check or deposit slip for verification of account number.

*This authorization is to remain in effect until revoked by consumer in writing. Until KVNet actually receives such notice, consumer agrees that KVNet shall be fully protected in honoring any such draft or check to consumer’s checking account. Each month 20 days before due date, KVNet will email or mail consumer a copy of the bill. Accounts with insufficient funds will be billed the applicable charges per occurrence.Please drop off at any Nolin Office or mail application with voided check or deposit slip to:

KVNet Inc.

P.O. Box 547

Elizabethtown KY 42702