Authorization Agreement for VSC Affiliates

DIRECT PAYMENT

I (We) hereby authorize SoVerNet, Inc. hereinafter called company, to debit my (our) account indicated below and the financial institution named below, hereinafter called financial institution, to debit the same to such account.

It is understood that no bill will be sent, and the fees will be debited in advance in accordance with the payment-period selected:

      ____ Monthly    ____ Annually*    ____ 8-Month Prepay*


Financial Institution: _________________________________________________________


Branch: ___________________________________________________________________


Address: __________________________________________________________________


City/State: ______________________________________/_____ Zip: _______________



Type of Account: ____ Checking   ____ Savings


Account Number** _________________________ Routing Number***__________________________


* Prepay amount will be withdrawn once at the start of the period. Annual Prepay is only
for Dial-Only Accounts; 8-Month prepay is for Single- or Multi-User Dialups. At the end of the period, 
withdrawals in the amount then in effect for the account and any associated services, 
will commence on a monthly basis unless other payment instructions are received.

** The Account Number is printed at the bottom of each check


*** The Routing Number (sometimes called ABA number) is also printed on 
the bottom of each check, to the left of the Account Number

If you bank with a Credit Union---Please contact them to get the proper ABA and Account Number to use for electronic withdrawals. The numbers which appear on your checks are not necessarily the correct ones to use for this purpose.

This authority is to remain in full force and effect until company has received written notification from me (or either of us) of its termination in such time and manner as to afford company and financial institution a reasonable opportunity to act on it.

Please print your full name: ____________________________________


SoVerNet Account-Username: ___ ___ ___ ___ ___ ___ ___ ___ 


Signature: ____________________________________________ Date: _____________________

Please Attach Copy of Voided Check to This Form!

Fax to (802) 463-2110 or US Mail to SoVerNet, POBox 495, Bellows Falls, VT 05101