Automatic Payment Authorization

Please fill out the form below to apply for automatic payment deductions. Your account number and billing information can be found by logging into your billing account here:

If you have any questions or concerns, please contact our Billing Department at (888) 438-8436.

Payment Type:*
First Name:*
Last Name:*
Account Number:*
Email Address:*
Email Address Confirmation:*
Authorization Date:*

I authorize SAA Bright.Net to deduct my payment from my credit card or bank account automatically.

Agreement Choice:*

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