DIRECT PAYMENT SERVICE

The IAW Direct Payment plan allows us to automatically debit your bank account. To sign up, fill in and return this sheet to the company with one of your personal cheques unsigned and marked VOID (for Verification Purposes)

ENROLL AUTHORIZATION CARD

I/WE

Name(s):_________________________________________________________

Address:_________________________________________________________

City:_______________ Province:___________ Postal Code:_________

AUTHORIZE

Internet Access Worldwide "the Company"
3 East Main Street
Welland, Ontario
L3B 3W4

TO DEBIT MY/OUR ACCOUNT ACCOUNT NUMBER:__________________

Held at:_________________________________________________________

(Name Of Financial Institution)

_________________________________________________________________
Branch Address Transit No.

For the purpose of monthly charges for the services provided by Internet Access Worldwide

FOR VARIABLE AMOUNTS NOT TO EXCEED $__________, payable monthly beginning___________________(date)

I/We have read and understood the terms of this authorization and acknowledge recipt of a copy therof. 



___________________			____________

Signature				Date
 
 
 

___________________			____________

Signature				Date
 

 

*For joint accounts, all depositors must sign if more than one signature 
is required on cheques issued against the account.
 
 

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