Credit Card Payment Authorization Form

Millry Communications

Automatic Monthly Credit Card Payment Authorization

CREDIT CARD BILLING INFORMATION

Select One:

___ VISA

___ Master Card

Card # ___________________________ PIN ________

Expiration Date: Month____________ Year _________

Signature:______________________________________

AUTHORIZATION

I hereby authorize MILLRY COMMUNICATIONS to automatically charge my credit card for my bill each month on the bill due date. I may cancel this request by contacting MILLRY COMMUNICATIONS.

CUSTOMER INFORMATION - PLEASE PRINT

Name:___________________________________________

Address:_________________________________________

City, State, Zip:___________________________________

Phone Number:_______________________________

For confidentiality, this form will be filed in Automatic Credit Card Payment file in company safe.

Interoffice Use ONLY:

Subscribers Name:__________________________________

Telephone Number:__________________________________

Completed by:______________________________________

Date Completed:____________________________________

Return completed form to: MILLRY COMMUNICATIONS, PO Box 45, Millry, Alabama 36558