JAX Computers Inc. DBA JLA Associates

Automatic Monthly Credit/Debit Card Deduction Form

I ________________________ authorize Jax Computers Inc. DBA JLA Associates to bill my credit card for the monthly service fees in the amount of $__________. I understand that this is a recurring monthly transaction that will begin on ______________ and will continue until cancelled in writing. I understand that unless this authorization is cancelled in writing via e-mail or regular mail that it will be continued on a monthly basis from this day forward.

______ I understand that only the monthly service fees will be automatically deducted and that any other charges will be billed separately.

______ I authorize all charges to be billed automatically from my credit card upon completion of any work or for domain renewal fees.

_______ I authorize all invoices to be paid in full monthly from this credit card.

CARD TYPE:____________________

CREDIT/DEBIT CARD NUMBER:_____________________________________

EXPIRATION DATE:___________

CARD CODE:_________

NAME ON CARD:_________________________________

BILLING ADDRESS:_________________________________

BILLING CITY:_______________________________

BILLING ZIP CODE:____________________________

PHONE:_____________________________

SIGNATURE:_________________________

DATE:___________________________