Payment Arrangement Agreement

PAYMENT ARRANGEMENT AGREEMENT

Licking Valley RECC offers two options to sign up for a payment arrangement.

Option 1 – Complete the online application below. This does require you to upload a valid Drivers License for proof of identity. Sending personal information over the internet is never 100% secure. Please do not include your full Social Security Number. We will call you once we receive your application for the payment arrangement and get the remainder of your information at that time.

Option 2 – Drop in our Business office in West Liberty during normal working hours.

Today's Date & Time *

Date

Time

Account Number *

Valid Account # must be provided.

Applicants Information

Applicant's Name *

First

Last

Last 4 digits of Social Security Number *

Copy of Valid Drivers License *

Click or drag a file to this area to upload.

Use this location to upload a copy of your DL. If you wish to provide this in a more secure manner, it can be brought by our business office.

Email *

Home Phone *

Mobile Phone

Work Phone

Current Mailing Address

Current Mailing Address *

City,State *

Zip Code *

Additional Comments

Digital Signature

Digital Signature *

Checking this box confirms the applicant agrees to honor the final payment arrangement established with one of our member service representatives. Breaking a payment arrangement will result in service being disconnected and the full balance being paid prior to service being reconnected. A Licking Valley RECC Representative will contact you regarding your application.

Digital Agreement *

I understand that checking this box and typing my name in the field provided below is my digital signature

Type your Full Name here to sign this Document Digitally.

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