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Secure Payment by Check

Required fields are denoted with a red asterisk (*).

I prefer to print and mail this form

Check Information

Authorization Agreement for Preauthorized Payments

I (we) herby authorize Proulx Oil & Propane to initiate debit entries to my (our) account for the amount indicated below and the depository named below.
One Time Charge? Yes     No
Recurring Charge? Yes     No
*Date of Deduction:
(select one) One time Charge
*Depository Name:
*Depository City:
*Depository State:
*Depository Zip Code:
*Bank Routing Number:  
*Bank Account Number:  
Checking     Savings
*Proulx Account Number:
*Zip Code:
*Phone Number:
*Email Address:

This authority is to remain in full force and effect until Proulx Oil & Propane and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford Proulx Oil & Propane and DEPOSITORY a reasonable opportunity to act on it. Proulx will require written notification at least 10-days before the schedule withdrawal to stop an automatic payment.

If a payment is rejected and returned to Proulx, the customer must re-submit a payment and the account will be charged a $37 handling fee.

I Agree     I Disagree

Would you like to receive email reminders and special promotions from Proulx?
  Yes, please notify me
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What is six+eight?
  Why are you asking me this?
(enter your answer as a number, as in six+one=7)

At Proulx Oil & Propane, we believe that safeguarding your online privacy is our responsibility. We have not, nor will we ever sell, rent or make available for use, your personal account information to any third party. Your e-mail address will be used only to e-mail reminders and early notifications of special promotions from Proulx if you choose to be notified.