Please print this form, fill in the details, and return it to NRG. FAX 02 6622 4773 or Post PO Box 1259 Lismore NSW 2480

Auto-Payment Form
This form is to authorise NRG to deduct your credit card monthly for your Monthly account.

PAYMENT AUTHORISATION



I, , hereby authorise Nornet Enterprises Pty Ltd Trading as
Northern Rivers Gateway (NRG) to automatically debit my credit card each month for payment of my Monthly Internet Access Account until further notice.

Signature:      Date:

NRG Username:


PAYMENT DETAILS


Credit Card Type:   Visa Mastercard Bankcard American Express
Credit Card Number:         
Security Reference Numbers CVV:* Visa / Mastercard / Bankcard:
American Express:
Cardholders Name:
Expiry Date: /


Nornet Enterprises Pty Ltd
Trading as Northern Rivers Gateway (NRG)
ABN:75 097 787 892
PO Box 1259 Lismore NSW 2480
Ph: (02) 6622 3488, Fax: (02) 6622 4773, Email: admin@nrg.com.au

* Security Reference Numbers or CVV 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)

CVV is an anti-fraud security feature to help verify that you are in possession of your credit card. For Visa/Mastercard/Bankcard, the three-digit CVV number is printed on the signature panel on the back of the card immediately after the card's account number.

Example Below:

Visa/MasterCard/Bankcard CVV Number