- Credit Card Authorization Form

NETCONNECT CREDIT CARD AUTHORIZATION FORM

Please Print and mail this form to us.
Credit cards will be billed monthly, until Netconnect receives written cancellation of service. 30 days are required to stop service. Full refunds for unused whole months are issued by check, but partail unused months are not refunded.

Card Type (circle one) : MASTERCARD VISA DISCOVER

Card Number: _________________________

Expiration Date: _______/_______/________

Card Holders Name: ___________________________________________

(exactly as it appears on the credit card)

Billing Address: _________________________________________________

City__________________________________________

State __________________ ZIP __________________

Card Holder Phone Number:( )________-______________

Card Holder Signature:	_______________________________
Card Holder Name (PRINT):	_______________________________
Date Of Signature:	_______/__________/_____________

Please print out this form, sign, and return to Netconnect. Netconnect must have this form on file to bill your credit card. In the event that you do not give Netconnect 30 days to cancel your service and issue you a refund for any unused months, and initiate a credit card chargeback, due to your failure to give 30 days cancelation notice to Netconnect, a $100 chargeback fee will billed to you.

Return To Netconnect's Homepage