Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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: 300 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)
