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I hereby authorize NetWest AutoPay  to charge, on behalf of NetWest Online Inc., the monthly amount shown below to the checking or credit card account listed.


Checking Account
(Attach a voided check)

Credit Card
Exp. Date _____ / ______
 
Account Number : ______________________________________
 
Amount: $________________
 
Beginning:  _____/_____/_________
Company Name:  NetWest Online Inc.
 

TERMS AND CONDITIONS
(please read carefully)

Each month, the account I have indicated above will be charged automatically for the amount shown above.

It is my responsibility to ensure that there are enough funds available in the account designated to cover the amount due shown above. If a charge to my account is rejected because of insufficient funds, CP Automation Inc. will charge my account a return item processing fee of $25.00.

This authorization to charge my account shall be the same as if I had personally signed the check.

I understand that a record of my payments will be included in my bank/credit card statement. I have the right to have any erroneous entry corrected. This must be done within 45 days after the debit was made.

I may revoke this authorization by providing 30 days written notice, by certified mail to: NetWest Online Inc. , 5000 E. University Suite 11, Odessa Texas 79762.

 
Signature: __________________________________________

Print Name: _________________________________________

Date: ______/______/__________

Phone Number:  (______) ______________________

Please print this form and mail to:
NetWest Online
5000 E. University Suite 11
Odessa, Texas 79762
(remember to attach a voided check if applicable)

 
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