GoCom Canada Inc
P.O. Box 522, Bolton, Ontario, L7E 5T4
Phone / Fax: (800) 718-1807


Pre-Authorized Payment Authorization

Personal/Household PAD [   ] or Business PAD [   ]
(select one of the above)

____________________________________________________________________________________________________
Payor Name(s)

____________________________________________________________________________________________________
Address

____________________________________________________________________________________________________
City & Province

____________________________________________________________________________________________________
Postal Code

____________________________________________________________________________________________________
Phone Number

I (we) authorize GoCom Canada Inc to process a debit, in paper, electronic, thrid party or other form.

The amount of the debit will vary and will be identified to me via a personal e-mail at least 20 calendar days in advance of the payment date as pre-notification. The amount of the debit will be affected by the following items: (1) the billing amount of service(s) I selected for the upcoming billing month, (2) any over limit usage from the previous billing month, and (3) credit or debit adjustment related to the service or to billing problems.

If after 10 calendar days of debit pre-notification I (we) require changes or cancellation of debit, I (we) will compensate GoCom Canada Inc in the amount of $25.

I (we) acknowledge that I (we) have read, understood and accepted all the provisions contained in the Terms and Conditions of the Pre-Authorized Payment Authorization.

Personal/
 Household
PAD only

  ________________________________________________________________________________
signature of Payor(s)
  ____________________
Date
     

Business
PAD only

________________________________________________________________________________
Name(s) of Authorized Signing Officer(s)

________________________________________________________________________________
Signature(s) of Authorized Signing Officer(s)

____________________
Date


PRE-AUTHORIZED PAYMENT AUTHORIZATION - TERMS AND CONDITIONS

DEFINITIONS