C3I Credit Card Agreement

Once your account is set up, if you are paying by credit card, you must fill out, sign and mail us the following agreement, which authorizes us to process additional payments as due.

Instructions:

1)		Enter all information into the following form (All information is required)
2)		Print the form (Press the Print button on your browser or the Print button at the bottom of this page; Don't forget to print a copy for yourself!)
3)		Sign the form and mail to:
		Computer Consulting Centers, Inc. 3819 Windway Orlando, FL 32817

I, , authorize Computer Consulting Centers, Inc., to charge my
(enter name as it appears on credit card),

credit card, account number ,

expiration date, /,

for my Internet Service payment beginning 1st, .

Email Address:

This agreement will remain in effect until cancelled in writing by either party.

Signature: _____________________________ Date: _________