DSL
vaughns.com Internet Service DSL(DSL Order Form)
Vaughn's Computer Central
*2524 NE Vivion Rd * Kansas City, MO 64118 * 816-455-1600
User Name: _______________Password: __________________Starting Date: _________________
Name: ________________________________________________
Customer Address: _______________________City________________State_________ZIP________
Customer Phone Number: _______________________________
-------------------------------------------------------------------------------------------------
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
$29.95 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 _________________, 2006.
X_______________________________________________
-------------------------------------------------------------------------------------------------
CREDIT CARD AUTHORIZATION
Address Numbers: _________________Zip: __________ 3 Digit CRC Code: ______
credit card #: _________-___________-___________-__________ expiration date: __________
The undersigned hereby authorizes Vaughn's Computer Central
to charge my credit card in the amount of
$29.95 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 _________________, 2006.
X______________________________________________________