Account Number(Required) Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Checking or Credit?(Required) Checking Account Credit Card Name of Financial Institution(Required) Address of Financial Institution(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Checking Account Number(Required) Financial Institution Routing Number(Required) Attach Copy of Voided Check(Required)Max. file size: 300 MB.Member Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.I authorize Jefferson Davis Electric Cooperative and the Financial Intuition named below to initiate entries to my checking account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the Financial Intuition 3 days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to 15 days following issuance of my Financial Intuition statement or 60 days after posting, whichever occurs first.Member Electronic Signature (Full Name)(Required) Name on Credit Card(Required) Type of Credit Card(Required) Credit Card Number(Required) Expiration Date(Required) CCV Code Number(Required) *A convenience fee of $3.95 per every $300 will apply each month.Attach Copy of Front and Back of Card(Required) Drop files here or Select files Max. file size: 300 MB. Member Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.I authorize Jefferson Davis Electric Cooperative and the Financial Intuition named below to initiate entries to my checking account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the Financial Intuition 3 days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to 15 days following issuance of my Financial Intuition statement or 60 days after posting, whichever occurs first. Member Electronic Signature (Full Name)(Required)
