If you currently have an account with Interlog, and would like to use our automatic credit card debiting plan to maintain your account, print and fill this form out, then fax it to us at 416-975-9639.
PLEASE PRINT, AND ENTER ALL INFORMATION AS IT APPEARS ON THE CARD
Name (as it appears on card): ________________________________________
User Name (shell login):__________________________
CARD TYPE (circle one): ---Visa--- ---Amex---
Card #: _____________________________________ Expiry Date ____ /____
I would also like to authorize a one-time debit of $______.__ for ____ months of ________ service to take advantage of Interlog's pre-payment discounts.
I (we) authorize Interlog Internet Services to process a monthly debit, in paper, electronically, or any other form on my credit card in the amount neccessary to render my account with Interlog to a positive balance.
I (we) understand that written notice must be received by Interlog 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:_____________________
Fax this completed form to: 416-975-9639
Mail this completed form to: 1075 Bay St., Suite #510, Toronto ON, M5S 2B1
Copyright 1995 - Interlog Internet Services