Name: ______________________________________________________________________
Address:
____________________________________________________________________
City,
State, Zip _______________________________________________________________
Telephone
Number: ___________________________________________________________
Email
Address: _______________________________________________________________
Circle Credit Card Type: VISA | Master Card
Name
on Card: ______________________________________________________________
Expiration
Date: ______________________________________________________________
Security
Code: __________________________
I authorize
995web.net and Boca-Industries to charge my credit card for $100 for setup fee
for DSL service. In the event that DSL cannot be configured within seven days
on my existing telephone number from the date of the order acceptance, I will
be refunded the $100 setup fee. The setup fee includes any required customer premise
equipment which will be shipped to me within seven days.
Security
Policy: 995web.net and Boca-Industries
offers credit card acceptance offline for users uncomfortable with online credit
card processing. The fax machine is a physical device, located in a locked office.
Your credit card authroization will remain onfile, in a locked file cabinet, in
a locked accounting office.
