T-MOCSYS
Automatic Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete following information, sign and send us the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.

Customer Information:

Customer name: _____________________________________

Address: _____________________________________ Zip code__________

Phone: ___________________, Email:_____________________

Payment Information:

I authorize T-MOCSYS to automatically bill the card listed below as specified:
Amount (Select your current plan ):
( Standard $17.95,      Family $22.95,      Email Only $5.00,
  *Airnex Standard $14.95,      *Airnex Family $19.95,      *Other $________ )
Frequency: Monthly
Start billing: January, 2007
End billing when: Customer provides written cancellation
( * Airnex and other promotional rates are for current customers on the plan only. )

Credit Card Information
T-MOCSYS accepts the following credit cards: Visa, Master Card

Credit card type: ( VISA, MASTER )

Credit card number: ____________________________________Expires:___/___/_____

Name on the card: ______________________________________(as shown on the credit card)

Credit card billing address (If different from above address):
________________________________________________________ Zip code:____________

Security Code: __________________  

Customer's signature: _______________________________ Date:___/___/____
                                      PRINT:

Please FAX signed form to 1-310-388-0984 or
Mail to: T-MOCSYS 805 S. Wooster St. #105 LA, CA 90035