Donation by MasterCard or VISA

Name on NCF Account ______________________________ NCF Account ID _________

Signed ______________________ Date ______________________

Signature of Parent or Guardian if under 18 _____________________

Phone ______________________

Street Address __________________________________________

City/Prov/Postal Code ____________________________________

I authorize National Capital FreeNet Incorporated to debit my VISA/MasterCard account

for the amount of $__________

ACCOUNT NUMBER ________ _______ _______ _______ Expiry _____/______

Name on card: _____________________________________