AutoPay Authorization Form

Please complete this form to authorize credit card payments and update your card on file for Ultra Pure Bottled Water Inc.

Ultra Pure Account Information

Account Name

Account Number

Account Number (000***)

Phone

Phone Number

Billing Information

First Name

Last name

Last Name

Street Address

City

State

Zip

Card Information

Payment Method

Auto Pay / Credit Card

Auto Pay / ACH Bank Transfer

Autopay customers will be billed on the 1st of every month for the previous months water delivery service.

Authorization (Cardholders Signature)

By signing below, I hereby authorize Ultra Pure Bottled Water Inc to auto bill the payment selected above for monthly transactions associated with this account.

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