Electronic Payment Authorization

Use this form to provide GBU with the relevant information for refunding your deposit.

Fill out Electronic Payment Authorization Form (For Refund of GBU Deposit). If the Outstanding Balance on the account is more than the deposit held on the account, the outstanding balance must be satisfied by payment or signing a payment arrangement.

Vendor Information
Company Name
Trade Name
PO Box*
Physical Address on File with Bank
Subdivision Street Name Lot & Block Unit P.O. Box
Email Address*
Telephone No*
Email Address (for remittance)*
**The Remittance email detailing the invoice number, invoice amount paid, date of the payment and the total dollar value of the payment will be sent to the remittance email address specified above.
Company's TIN
Banking Information
Name on account*
Bank Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Name*
Bank Code*
Branch Code*
Account Type*
- Checking
- Savings
Account Number*
Physical Address on File with Bank (if different from above)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Authorization*
- I/We hereby authorize direct payments electronically to the bank account specified here. I/We hereby agree to submit information immediately should our banking information change.
Signature*
Your Name*
Title
For security purposes, please check the box below

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Help Desk

Electronic Payment Authorization

Vendor Information

Banking Information

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Account & Billing

Customer Care

Our Company

Help Desk

Account & Billing

Customer Care

Our Company

Help Desk

(242) 350-9000

customerservice@gbwater.com

(242) 350-9000

customerservice@gbwater.com