Credit Card Auto Pay Authorization

TDE Account Name:
(shown on your statements)
(typically the left side of email address)

Company Name:
(if applicable)
First Name:
Last Name:
Credit Card Number:
Credit Card Expiration Date (MM/YY):
Cardholder's Name:
(as it appears on the credit card)
Credit Card Billing Address:
(as it appears on the credit card statement)
Street:
City:
State:
Zipcode:
Daytime Telephone:
Evening Telephone:
Email Address:

Additional Instructions:
(if applicable)

I hereby authorize The Denver Exchange, Inc. to charge all amounts due on the TDE Account indicated above, to the credit card indicated above. I understand that it is my responsibility to provide TDE with updates to the information provided above (e.g., credit card number, credit card expiration date, credit card billing address, etc.) as needed, and that failure to do so may result in late fees, reconnect fees, and/or interruption of service due to past due balances on the TDE Account indicated above. I understand that I can revoke this authorization at any time, and that this authorization will remain in effect until revoked by me via written notice mailed to Accounts Receivable, The Denver Exchange, Inc., PO Box 11271, Denver, CO 80211-0271.


security code

Enter the Security Code shown above:


 



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