Credit Card Info & Authorization & Recurring Billing Contract
I authorize Western Canada Internet to keep my signature on file and to charge my credit card
I understand that this authorization is valid for one year from the below date unless
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:
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________
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.
Card Holder Signature ___________________________ Date___________________
Western Canada Internet