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									                                                            Credit Card Payment/ACH Withdrawal Authorization
                                                                     PO Box 7, 35 South State, Fairview, UT 84629 | (435) 427-3331 | (800) 427-8449




 Customer Information

Enjoy the convenience of automatic payments with your credit card or a direct withdrawal from your bank account (ACH). Your bill will
always be paid on time. The balance on your telephone/Internet/cable TV statement will be paid automatically between the 15th and
20th of each month.

You will receive a statement approximately ten days prior to the withdrawal. That leaves you time to review the bill before it is paid. Please
choose one of the payment options below and return this form to our office.

Customer Name:                                                         Account Number:


Automatic Payment Options (Fill out one of these options)
 Option 1: Credit Card Payment Authorization                              Option 2: Automatic Withdrawal (ACH) Authorization

I hereby authorize CentraCom Interactive to initiate a monthly           I hereby authorize CentraCom Interactive to initiate debit entries
charge to my credit/debit card named below. This authorization           to my account at the financial institution named below. This
is for the purpose of automated payments of my monthly tele-             authorization is for the purpose of automated payments of my
phone/Internet/cable TV statement.                                       monthly telephone/Internet/cable TV statement.


Type of Card:      Visa     MasterCard       Discover      Amex          Financial Institution:

Credit Card Number:                                                      Branch:

Expiration Date:                                                         Financial Institution Account #:

V-Code (Last three digits of number in signature panel)                  Account Type (Check one):           Savings       Checking

Card Billing Address:                                                    Please attach a VOIDED CHECK with this form

City:                          State:          Zip:




Signature                                                                                            Date

								
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