Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)RushShelby Energy Account Number(Required) Bank Name(Required) Checking Account Number(Required) File Upload(Required)Please attach a voided check to this form. Max. file size: 100 MB.Member Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.I authorizeRushShelby Energy (RSE) to draw monthly bank drafts on my account shown above for the payment of my monthly statement. I understand that I can discontinue my participation in the APP by notifying RushShelby Energy in writing. Both RSE and my bank may also terminate this agreement with 10 days written notice. I understand that RSE reserves the right to limit participation in the APP to customers whose accounts are in good standing.Member Electronic Signature (Full Name)(Required)
