Credit Card Authorization Form

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Please complete this form, print, sign and mail to the address below.

Name On Credit Card

  

Credit Card Number

  

Expiration Date

  

Payment Plan

(Please Check the plan you desire)

$210 Annual

119.70 Semi-annual

59.85 Quarterly

 

I here by authorize Local Net Plus, LLC to charge the above selected amount to my credit card at the intervals selected.  Furthermore, I acknowledge that the Credit Card information presented above is in fact my card.  I also understand that if I wish to be removed from Credit Card billing, I must Notify Local Net Plus, LLC prior to the next scheduled charge date for my account.  If I fail to notify Local Net Plus, LLC of my desire to be removed from Credit Card Billing before the next charge date, my card will be charged, and the full amount will be credited to my Internet Service account.  NO REFUNDS WILL BE ISSUED FOR CREDIT CARD CHARGES.  Failure to report change in Credit Card Number or Expiration Date could result in Service Cancellation or additional processing fees.  Once this completed form is received, you will be entered into repeating credit card billing.

 

Agreed and Accepted by:

 

Name: (Print your name)

Signature:

 

Date:

Billing Address

(Address where your credit card statement is sent)

Phone Number:

 

 

 

Please Print this form and return to:

Local Net Plus, LLC

57051 Marietta Road

Byesville, OH  43723