Level Pay/Bank Draft Disenrollment Application
Please indicate the program you wish to discontinue:
Bank Draft
Level Pay
Account Number: ___________ - __________ Route Number: _____
Customer Name (s): _____________________________________________________
Service Address: _______________________________________________________
Home Phone Number: (______) ________________
Work Phone Number: (______) ________________
E-mail Address (Optional): _______________________________________________
By signing below, I give my approval to be taken off the program indicated above. I am
also aware that if I wish to be enrolled in the p
rogram again, a new application will have
to be submitted.
Signature: _____________________________ Date: _____ / _____ / _____
Office Use Only:
Received by: __________________ Processed By: __________________
Date: _____ / _____ / _____ Date: _____ / _____ / _____
City of Banning
99 East Ramsey Street, PO Box 985, Banning, CA 92220
Tel: (951) 922-3185 Fax: (951) 922-3165 Email:ubweb@banningca.gov
www.banningca.gov
