Credit Card Authorization Form

If you currently have an account with Echo Online Internet Inc., and would like to use our automatic credit card debiting plan to maintain your account, print and fill out this form, then mail it to Echo Online Internet Inc. at 2600 Skymark Ave., Building 9 Suite 201, Mississauga, Ontario L4W 5B2 or optionally fax it to us at 416-385-0469.

PLEASE PRINT, AND ENTER ALL CONTACT INFORMATION

    Name:______________________________________________________

    Address:__________________________________________________

    City:________________________ Province:____________________

    Postal Code:______________________

    Phone Number:________________ Fax Number:__________________

PLEASE PRINT, AND ENTER ALL INFORMATION AS IT APPEARS ON THE CARD

    
    Name (as it appears on card): ________________________________________
   

    User Name (email/shell login):________________________________________
    
      CARD TYPE (check one): Visa Master Card  American Express
    
    Card #: _____________________________________ Expiry Date ____ /____ 
    
    I would also like to authorise Echo Online Internet to Bill my Credit Card
    monthly on my account renewal date.  Yes No
    
    I (we) authorise Echo Online Internet Inc. to process a monthly debit, in
    paper, electronically, or any other form on my credit card in the amount 
    necessary to render my account with Echo Online Internet Inc. to a 
    positive balance.
    
    I (we) understand that written notice must be received by Echo  
    Online Internet Inc. in order to terminate this agreement.
    
    I (we) warrant that all persons whose signatures are requested to sign on
    this account have signed and received a copy of this agreement.


    Date:______________  Signature: x_____________________________________


    Print Name:____________________________________________________


    Date:______________  Signature: x_____________________________________


    Print Name:____________________________________________________
    
    Mail this completed form to: Echo Online Internet Inc. at 
    2600 Skymark Ave., Building 9 Suite 201, Mississauga, Ontario L4W 5B2
    or Fax this completed form to: 416-385-0469