Name:_______________________________________________________

Tel: (_______) ____________________________ Fax: (_______) ______________________

Address: ________________________________________________________________________

City/State/Zip: _________________________________________________________________ 

Date of Birth: ______________________   Username: ___ ___ ___ ___ ___ ___ ___ ___
      

This Agreement authorizes SoVerNet, Inc to deduct charges incurred for the use of SoVerNet’s “Remote Dial-In Service” for which I hereby subscribe.

I understand that SoVerNet will email my base account monthly with the total Remote Dial-In charges incurred that month.

Payment will be by the method currently selected for payment of my Internet service account.

     Notes:
        • Monthly payment by check—due date is the same as for regular account
        • ACH withdrawal—payment to be automatically deducted with fee(s) for regular account
        • Pre-paid accounts—Remote Dial-In charges payable within 30 days of billing date.
        • Usage will be at the rate of 11-cents per minute, in full-minute increments.
        • Additionally, I understand there will be a $1.00 (one dollar) minimum charge for any month in which
          the service is used. If the Service is not used, there will be no minimum charged that month.
        • If payment for service is not made within 30 days of billing, the account will be subject to suspension.

If I no longer wish to purchase this service I must send a verifiable request (from my SoVerNet account to staff@sover.net, or in writing with my signature via fax or US Mail) to terminate this Agreement prior to the next billing date. I remain responsible for charges accrued prior to receipt of the termination letter by SoVerNet.

Signature: _________________________________________ Date: ________________
      

Sign and return to SoVerNet, POB 495, Bellows Falls, VT 05101 or fax to (802) 463-2110