Date:  

I    hereby authorise ADNET Audio & Internet to direct debit my 
credit card (each month YesNo) or (once only YesNo)
for amounts owing on my Internet access account - Account Name (username) 


I understand that should I wish to terminate this arrangement I must do so in writing.

Please charge my
Bankcard: YesNo
Visa: YesNo
Mastercard: YesNo
American Express: YesNo
Diners Club: YesNo

( )For the amount of:    or
( ) amount owing each month or
( ) when I advise by email/phone/fax (Please tick)

	Card Number:  Expiry Date: 

   	Cardholders Name:  

Signature.....................................................