vaughns.com Internet Service

Vaughns.com Internet Service

*6261 N Oak Trafficway* Gladstone, MO 64118 * 816-455-1600


User Name: _______________Password: __________________Starting Date: _________________

Name: ________________________________________________

Customer Address: _______________________City ________________State _________ZIP ________

Customer Phone Number: _______________________________

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BANK DRAFT AUTHORIZATION
Social Security Number: ______________________________

Bank Name: ______________________________

Account Number: ______________________________

The undersigned hereby authorizes Vaughn's Computer Central
to draft my checking account in the amount of
$14.95 every month for Internet services rendered.
This authorization shall remain in effect until such time as the undersigned
shall cancel service with 30 days prior written notice.

Signed this ____________ day of _________________, 2013.

X_______________________________________________

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CREDIT CARD AUTHORIZATION

Name: _______________________________________________

Address: ____________________________ City:____________________

State: ________ Zip:__________

credit card #: ________________________expiration date:___________

The undersigned hereby authorizes Vaughn's Computer Central
to charge my credit card in the amount of
$14.95 every month for Internet services rendered.

This authorization shall remain in effect until such time as the undersigned
shall cancel service with 30 days prior written notice.

Signed this ____________ day of _________________, 2013.

X______________________________________________________