Santel Internet - Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM (Print this page, fill out and return to address below.)

RETAIN FOR YOUR RECORDS

On (date) ______________________ I authorized Santel Internet, dba Santel Communications Cooperative, to initiate variable entries to my VISA or MASTERCARD credit card account for payment of monthly internet service from Santel Internet, dba Santel Communications Cooperative, and agreed to the terms listed on the authorization.

(Detach here and return lower portion to Santel Internet)

AUTHORIZATION FOR AUTOMATIC PAYMENT BY CREDIT CARD

I authorize Santel Internet, dba Santel Communications Cooperative, and the financial institution named below to initiate variable entries to my credit card account. This authority will remain in effect until I notify you in writing to cancel it in such terms as to afford Santel Internet, dba Santel Communications Cooperative, opportunity to act on it. I authorize scheduled payments to be made by charging to my credit card account between the 15th and the 20th of each month.

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NAME OF FINANCIAL INSTITUTION (CREDIT CARD PROVIDER)

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ADDRESS OF FINANCIAL INSTITUTION

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DATE

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SIGNATURE

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NAME (PLEASE PRINT)

__________________________________________________________
ADDRESS (PLEASE PRINT)

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PHONE NUMBER

CREDIT CARD: _____ VISA _____ MASTERCARD _____ DISCOVER

CREDIT CARD NUMBER _______________________________________

EXPIRATION DATE __________________________________________

EFFECTIVE DATE FOR AUTOMATIC PAYMENTS ____________________

Return to:

Santel Internet
P.O. Box 67
Woonsocket SD 57385-0067

For more information, call us at 1-888-796-4411