Name:_______________________________

Address:____________________________

Phone:______________________________

Credit Card(please circle):     Visa     Mastercard     American Express

Credit Card Number: |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|

Expiration Date: |__|__|__|__| (m m y y)

Username:_____________________________

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I authorize the payee to debit my credit card as indicated below under the terms and conditions agreed to by me with the payee until such time as written notice to the contrary is given. Termination of this authorization does/may not terminate the contract for the goods or services-exchanged. I will notify the payee in writing of any changes in the credit card information or termination of this authorization prior to the next due date of the debit. Items charged under any of the following conditions will be reimbursed subject to notification by me to the credit card company within 90 days. a) I never provided authorization to the payee. b) The debit was not drawn in accordance with my authorization. c) My authorization was revoked.

I authorize Internet Kent to bill my credit card in the amount indicated on the invoice emailed to me on the first of each month. The debit will be made on the 10th day of the month beginning in the month of ________________ , 200__.

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signature:__________________________ date:_____________

Print out, sign, and snail-mail or drop off this form to us or fax it to us at 519-627-7216.

InterNet Kent
435 James Street
Wallaceburg, ON
N8A 2N8