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 / Bankcard:
American Express:
Cardholders Name:
Expiry Date: /


Nornet Enterprises Pty Ltd
ABN:75 097 787 892
PO Box 1095 Lismore NSW 2480
Ph: (02) 6621 3215, 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 / Bankcard: 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)