When Filling out this form Please PRINT CLEARLY!

Credit Card Info & Authorization & Recurring Billing Contract 

I authorize Western Canada Internet to keep my signature on file and to charge my credit card 
account, on an ongoing basis (monthly where it applies) for amounts I owe. 

I understand that this authorization is valid for one year from the below date unless 
I can cancel this authorization through written notice or on-Line. 

I also agree to contact Western Canada Internet if there are any changes to my credit card account information. 

Please print and sign this form. Return it to:
Western Canada Internet
8410-182 Street. 
Edmonton, Alberta 
T5T 1Y7
or Fax it to (780) 439-5152 

NOTE! If we are to provide you with not present Credit Card service We require a signature. 

Full Name __________________________________  Company Name (if applicable) : ______________________

Address:   ____________________________________________  Postal Code: ___________________________ 

City: ________________________________  Phone: _______________________________

Visa / Master Card Account Number: ___________________________ Expiry Date:______________CVV2 info________
The CVV2 info: is located on the back of your card on the signature strip it is the last 3 digits following your card number

Name of Card Holder: ___________________________  Amount of Authorization $___________________________ 

By filling in the form above I acknowledge terms of Western Canada Internet and agree to abide by the rules and policies of same. I hereby agree to pay all charges incurred by me until the cancellation of my account. Western Canada Internet reserves the right to refuse or cancel service to anyone and change restrictions with out notice.
Note: Western Canada Internet is not responsible for the accuracy or content of the Internet and is not liable for loss or damages incurred by the use of that information.. (If not over 18 parent or guardian sign.)

Card Holder Signature ___________________________ Date___________________ 

Western Canada Internet
8410-182 Street. 
Edmonton, Alberta, T5T 1Y7
Voice (780) 413-1815 
Fax (780) 439-5152