SmartPay Budget 2015-2016
Customer Information
Sign me up for the SmartPay Budget Program, starting in
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July - 11 monthly payments
Aug - 10 monthly payments
Sept - 9 monthly payments
D.F. Richard Account Number
First Name
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Last Name
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Address
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City
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State
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Zip Code
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Phone Number
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E-mail
Payment Options
Options:
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Send me monthly statements.
Bill my credit card so I can pay automatically every month & get a 1-cent-per-gallon discount .
Set me up on your electronic funds transfer program & get a 3-cent-per-gallon discount.
If Paying by Credit Card
We accept MasterCard, Visa, or Discover
Name on Card
Credit Card Number
3-Digit Security Code
Expiration Date
I have read and agree to the terms of agreement
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Yes
If Setting Up Electronic Funds Transfer
Routing Number
Checking Number
Additional Comments/Notes
