Service Agreement and Credit Card Authorization

I authorize Public Interest Network Services to charge my credit card account or via Electronic Fund Transfer (EFT) for the provision of voice, data and other services specified in my service agreement.

Amount: $    

I agree to be responsible for all usage charges on my telephone service account and to provide notification to Public Interest Network Services of any disputed charges within (7) seven days of receipt of invoice.

Request to terminate authorization of recurring billing must be made in writing 30 days prior to the next scheduled payment.

All information entered on this form will be kept strictly confidential by Public Interest Network Services.

PINS Account #:
Company:
Telephone #:
Email:
 

Credit Cards:
Please charge my
Cardholder Name:
Credit Card #:
Expiration Date: Month:   Year:
Card Code #: (required)
AMEX - 4 digits on the front; VISA, MC,
Discover - 3 digits on the back
Credit Card
Billing Address:
City/State/ZIP Code:   
 

OR Use EFT:
Bank Routing #:
Bank Account #:
Name on Account:
 

Send Me:
 
Please send inquiries or disputes to: Public Interest Network Services, Inc.
50 West 17th Street, 9th Floor
New York, NY 10011
Email: billing@pins.net