Please print this form, fill it out, and return it as soon as possible. Without it, we will be unable to automatically charge your account for your monthly bill. Please let us know if you have any questions.
     Our address is 2407 Montana Ave, Billings MT 59101.  Our fax number is 406-255-9595

Effective date:

Name:

Address:

City:

State:

Zip/Post. code:

Phone:

Username

Check either Credit Card Billing or Automatic Checking Withdrawal

For Automatic Checking Withdrawal: please attach voided check

Checking

Savings

Financial Institution:

Transit Routing Number

Account Number Info.

Terms of service: Debits will be made on approximately the 2nd business day of each month. Automatic transactions will commence with the next billing cycle after authorization is received. Internet Montana will assess a $20.00 NSF fee on all transactions returned for non-sufficient funds.
Please note that bank authorizations take approximately 2 to 3 weeks to complete, therefore, authorizations received after the 20th of the month will not take effect in time for the next billing period.

For Automatic Credit Card Payment

Credit Card Number

Expiration Date:

Cardholder Name:

I authorize Computers Unlimited dba Internet Montana to automatically deduct my monthly Internet account charges from the above referenced account. I understand that this will be a recurring debit/charge until I provide written notice of its termination in such time and in such manner as to afford Internet Montana a reasonable opportunity to act on it. (minimum of 7 business days notice prior to effective date)

For credit card charges, I understand that if I change the credit card to which I am billed, this agreement will apply to the new credit card account provided to IMT.

Signature:

Date: