Internet Kent Pre-Authorized Chequing Form

Terms & Conditions I (we) authorize the payee to debit my (our) account as indicated on the attached "void" cheque under the terms and conditions agreed to by me (us) with the payee until such time as written notice to the contrary is given. I (we) acknowledge that delivery of my (our) authorization to the payee constitutes delivery by me (us) to the branch of the financial institution at which I (we) maintain an account and that such financial institution is not required to verify that the payment(s) are drawn in accordance with this authorization. Termination of this authorization does/may not terminate the contract for the goods or services exchanged. I (we) will notify the payee in writing of any changes in the account information or termination of this authorization prior to the next due date of the pre-authorized debit. Items charged under any of the following conditions will be reimbursed subject to written notification by me (us) to the branch of the account within 90 days. a) I (we), never provided authorization to the payee. b) The pre-authorized debit was not drawn in accordance with my (our) authorization. c) My (our) authorization was revoked. d) The debit was posted to the wrong account due to invalid/incorrect account information supplied by the payee. I (we) warrant that all persons whose signature(s) are requested to sign on this account have signed this agreement.

Pre-authorized Payment Authorization

Name:_______________________________

Address:____________________________

Phone:______________________________

Username:_____________________________

I (we) authorize InterNet Kent to process a debit, in paper, electronic or other form in the amount indicated on the invoice e-mailed to me (us) on the first of each month. The debit will be made on the 10th day of the month beginning in the month of _____________, 200__. I (we) acknowledge that I (we) have read and understood all the provisions contained in the terms and conditions of the pre-authorized payment authorization and that I (we) have a copy.

Signature:__________________________ Date:_____________

================================================================

Print out, sign, and snail-mail or bring in this form along with a cheque marked VOID to us. Or fax the form as well as a copy of a void cheque to 519-627-7216.

InterNet Kent
435 James Street
Wallaceburg, ON
N8A 2N8