Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below, print, sign the form, and return to us via mail. All listed information is required.

Upon approval we will automatically bill your credit card for the indicated amount, and applicable charges will appear on your credit card statement. You may cancel automatic billing at any time by providing written notification to us.

I authorize HighSpeedLink.Net to automatically bill the credit card listed below as specified:

Name of Cardholder:

Credit Card Type (American Express not accepted:)

Credit Card Number:

Credit Card Expiration Date:

Cardholder's Zip Code:



I understand that by signing I will
no longer receive a paper invoice, and
will receive electronic invoices at the
following e-mail address:




Customer Name (If different than Credit Card:)

Frequency (Check one!):

Monthly Quarterly (Quarterly Billing is available for dialup accounts only!)

Begin Billing On (Billing ends when customer provides written cancellation:)

Customer Phone Number: