"tiDlrs_submitting_
to
_TimcoUSA"
(Internet Communication Inc.)
Cities-cover
date
Account Type- - - -
Personal
Business
Basic Bus.
Integrated Serv. Digital Net.(ISDN)
Mail
Name
company (optional)
Address
City
State
Zip
Home Phone
Work Phone
Fax
Logon Username / User 2nd choice
ExtraEmail Name/ Name2ndchoice
PW
Pay Period
Monthly-----
Quarterly-
Annually ($200 = $16.67)
Method
Credit Card
Cash-------
Check IC
Monthly Stat
CrCrd type
MasterCard
VISA-------
AMEX----
Discover
Note: Monthly Billing, 1) Bill Credit Card $24.95 or 2) Mail Statement $26.95
Name as it appears on card
Card Number
Expires:
(Charges will be made during the week preceding the month for which payment is due)
I (We) hereby authorize Internet Communications, Inc., hereinafter referred to as "COMPANY, to initiate debit entries (withdrawals) to my (our) credit account as indicated above, and Credit Card company to debit the same to such account. This authority is to remain in full force and effect until COMPANY and Credit Card Company have received written notice from me (or either of us) of this term- ination in such time and in such manner as to afford COMPANY and Credit Card Company a reasonable opportunity to act upon it.
_________________________
Print Buyer Name
_________________________
Signature
__________________
Date
Total
Pay to ICI
Submit Form
Comments
Day
Fee
Setup
Total
1
20.80
2
20.00
3
19.20
4
18.40
5
17.60
6
16.80
7
16.00
8
15.20
9
14.40
10
13.60
Day
Fee
Setup
Next
Total
11
12.80
12
12.00
13
11.20
14
10.40
15
9.60
16
8.80
17
8.00
18
7.20
19
6.40
20
5.60
24.95
30.55
Day
Fee
Setup
Next
Total
21
4.80
24.95
29.75
22
4.00
24.95
28.95
23
3.20
24.95
28.15
24
2.40
24.95
27.35
25
1.60
24.95
27.55
26
0.80
24.95
25.75
27-31
0.00
24.95
24.95
.
Prepaid year $200 Save BIG!
Year
16.67
0
200.00
Copyright © 1999 Internet Communications Inc. , Timco, and 7days Auto stores. All rights reserved.