SureNet Communications - Pre-Authorized Payment Form

PLEASE PRINT, AND ENTER ALL CONTACT INFORMATION

Name:______________________________________________________

Address:__________________________________________________

City:________________________ Province:____________________

Postal Code:______________________

Phone Number:________________ Fax Number:__________________

User Name (email):________________________________________

I (we) authorise SureNet Communications Group Inc. to process a monthly debit, in paper, electronically, or any other form on my bank account in the amount necessary to render my account with SureNet to a positive balance.

I (we) understand that written notice must be received by SureNet Communications Group 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:____________________________________________________

Mail this completed form along with a voided check to:

SureNet
40 Main St. West
Huntsville, On
P1H 2C3

or

Fax this completed form and a voided cheque to: 705-789-2550