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2. Bank Name*
4. Bank Address1*
6. Bank Address2
8. City*
9. State*
10. Zip*
12. What type of account will be drafted:*

    1. Checking Account
    2. Savings Account
13. Account Number*
14. Routing Number*
16. Name as it appears on City of Goodlettsville Account
18. First Name*
19. Last Name*
21. Utility Account Number*
23. Driver's License*

    Upload applicant's driver's license

25. Service Address
27. Address1*
29. Address2
31. City*
32. State*
33. Zip*
35. Phone Number*
36. Email*
38. I give the authority to the City of Goodlettsville to bank draft my account for the payment of my monthly utility bill. I understand this authority shall remain in full force and effect until written notification of termination is received from me or until the City of Goodlettsville has sent me ten (10) days written notice that they will end this agreement. The City of Goodlettsville and the banking institution have a reasonable opportunity to act upon it. I understand that nothing contained in this Authorization shall serve to reduce my obligation to pay my utility bill and services may be disconnected, turned over to collections, and/or a lien placed on the property in addition to delinquency fees should I fail to have sufficient funds in the above-referenced account to cover the amount of the bill.*

    1. I agree.
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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