THE Competitive Internet Access
PO Box 1063
Seguin, TX 78156

Credit Card Authorization Form

Credit Card Type:



Card Number:_______________________________ Expire Date:______________

Name on Card:______________________________ TX Driver's License #:_________________
Credit Card Billing Address (where you receive credit statements):
City:_____________________________State:__________Zip Code:______________________

Automatic Payment (Optional):

I would like to automatically pay for my Internet service(s) each month/quarter/year with this credit card.

Please enter your initials:______________ Account Information: Username:________________________________________



I hereby authorize THE Competitive Internet Access to charge the amount shown above to the
card specified above. In addition, if I have initialed the automatic payment section above, I authorize
THE Competitive Internet Access to charge my card each month/quarter/year for all fees due that
period for the services I have subscribed to, until I notify them 15 days prior to the next billing date
in writing. I understand that the fees due will include the regular monthly/quarterly/yearly fees for
that period. I agree to pay the above credit card charges in accordance with the Card Issuer
Agreement. I understand that THE Competitive Internet Access will apply a chargeback fee to
my account ($45.00 as of the time this is written), if I initialize a chargeback with my credit card
issuer, to reverse payment without permission of THE Competitive Internet Access of any of the
charges authorized on this form, and I agree to pay this fee if this occurs.

Cardholder Signature:_________________________________________Date:_________________