DSL vaughns.com Internet Service DSL

*2524 NE Vivion Rd * Kansas City, MO 64118 * 816-455-1600 (DSL Order Form)

Email Address: __________________Password: __________________Starting Date: _____________

Your Name: ________________________________________________

Your Address: _______________________City ________________State _________ZIP________

Home Phone Number: _______________________________Cell: _______________________________

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BANK DRAFT AUTHORIZATION

Bank Name: __________________________________

Routing Number: ______________________________

Account Number: ______________________________

the undersigned hereby authorizes Vaughn's Computer Central
to draft my checking account in the amount of
o$29.95(T1 Download Speed) o$39.95(Super cool 3Mb) o$49.95 (SuperfastV 6Mb)

Every month for Internet services rendered.
This authorization shall remain in effect until such time as the undersigned
shall cancel service.

Signed this ____________ day of _________________, 2011.

_______________________________________________

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:
o$29.95(T1 Download Speed) o$39.95(Super cool 3Mb) o$49.95 (SuperfastV 6Mb)

Every month for Internet services rendered. This authorization shall remain in effect until such time as the undersigned
shall cancel service.

Signed this ____________ day of _________________, 2011

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