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Credit Card Authorization
Enetrics Communications is an MDM Enterprise Company
Customer Number: ____________(found on Invoice) <-- please fill in
Company Name: ______________________________________________ <-- please fill in
Email Address: ______________________________________________ <-- please fill in
Name On Card: ______________________________________________ <-- please fill in
Billing Address: ______________________________________________ <-- please fill in
City: ______________________________________________ <-- please fill in
State/Province, Zip: ______________________________________________ <-- please fill in
Credit Provider: ______________________________________________ <-- please fill in
Credit Card Number: ______________________________________________ <-- please fill in
Expiration Date: Month: _______ Year: _______ <-- please fill in
3 or 4 Digit Code: _____ (found on back of card) <-- please fill in
I authorize Enetrics Communications, an MDM Enterprise Company to debit my credit card as a monthly recurring charge
for their services rendered at agreed published prices. Should I dispute
a charge through my credit provider this will constitute a breach of contract
and will result in immediate deactivation of my server account. I understand that the name MDWA Solutions will appear on my credit card statement. This agreement for recurring credit card transaction is valid from 12/05/2008 to ____/____/_____ (MM/DD/YYYY).
Signature __________________________________________________________________ Date ________________
PLEASE NOTE: On your Bank Statements,
all charges from Enetrics Communications, will appear as MDWA Solutions.
INSTRUCTIONS
After you have reviewed complete the Billing Authorization Agreement,
please print, sign, date, and fax the Acknowledgment of Receipt and Execution
of Agreement (this document) to Enetrics Communications (480-461-9312). Mail
original to Enetrics Communications at address indicated below.
Enetrics Communications
6543 East Omega St
Mesa, Arizona 85215
US
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