Autodraft Authorization             Back to Payment Options Page

• Send us a voided check, checking deposit slip or credit card information with your signed authorization form (just print this page). Mail your completed form to Backroads Internet Inc., P.O. Box 1636, Laurens, SC  29360
• On the last business day of each month, we charge your credit card or checking account.
• Your payment appears on your monthly bank statement so you can keep track.

ELECTRONIC PAYMENT AUTHORIZATION NAME: _____________________________ ADDRESS: ____________________________________________________ CITY: ____________________________________________ STATE: __________ ZIP CODE: ________ PHONE #: ___________________ E-MAIL ADDRESS or ACCOUNT NUMBER: ___________________________________

PAYMENT METHOD (PLEASE FILL IN EITHER BANK OR CREDIT CARD TRANSACTION)

I. BANK TRANSACTION (ENCLOSE A VOIDED CHECK OR BANK DEPOSIT TICKET)

BANK NAME: __________________________________________________________________________ BANK ADDRESS: _______________________________________________________________________ CITY: ____________________________________________ STATE: __________ ZIP CODE: ________ BANK ACCOUNT #: _______________________________ ABA ROUTING NUMBER  _____________________ (THE ABA ROUTING CODE IS THE FIRST 9 DIGITS BETWEEN THESE    SYMBOLS)

II. CREDIT CARD TRANSACTION (PLEASE SELECT ONE CHARGE CARD) MasterCard   VISA   Discover   AmEx CARD#: ________________________________  EXP._______/_______

AUTHORIZATION

I (We) hereby authorize Backroads Internet Inc. to initiate debit transaction entries to my (our) account, indicated above. Financial institutions can make these debits by any means available, including the electronic transfer of funds involved. I understand that this authorization will be for the total amount due each month, in favor of Backroads Internet Inc. I understand that this authorization will be in effect until I notify Backroads Internet Inc. and my financial institution, if applicable, in writing that I no longer desire this service, allowing reasonable time for action on my notification. I understand non-payment due to insufficient funds in my account will be processed by my financial institution and Backroads Internet Inc. in the same manner as an insufficient funds check, and that I may be charged an insufficient funds processing fee by both. This debit process will be stopped upon termination of service.

SIGNATURE: _____________________ DATE: ____________