vaughns.com Internet Service

(DIALUP 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: _______________________________

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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 _________________, 2006.

X_______________________________________________

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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
$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 _________________, 2006.

X______________________________________________________