Please print this form, fill in the details, and return it to Nornet. FAX 02 66215356 or Post PO Box 1095 Lismore NSW 2480

Auto-Payment Form

This form is to authorise Nornet to deduct your credit card monthly for your Monthly account.

 

PAYMENT AUTHORISATION

 


I, , hereby authorise Nornet Enterprises Pty Ltd to automatically debit my credit card each month for payment of my Monthly Internet Access Account until further notice.

Signature:      Date:

Nornet Username:

 

PAYMENT DETAILS

 

Credit Card Type:

 

Visa

Mastercard

Bankcard

American Express

Credit Card Number:

        

Security Reference Numbers:*

Visa / Mastercard

 

American Express:

Cardholders Name:

Expiry Date:

/

 

Nornet Enterprises Pty Ltd
ABN:75 097 787 892
PO Box 1095 Lismore NSW 2480
Ph:1300 853 638, Fax: (02) 6621 5356, Email: nornet@nor.com.au

 

* Security Reference Numbers are displayed on the back of your card near your signature strip.
These 3 numbers (4 on American Express cards) are required by the Credit Authorisation companies

American Express: The 4 Security Reference Numbers are printed on your card near the end of your 15 digit card number.
Visa / Mastercard / The 3 Security Reference Numbers are printed on the back of the card, next to your signature (at the end of your 16 digit card number)

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Updating your Contact Details:

It’s really important we have your latest contact details please update here

Name: _____________________________________________________________

Username/Email address _______________________________________________

Address: ___________________________________________________________

Contact Phone Number: ________________________________________________