Monthly Donation by Credit Card Form

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 $__________ on or about the 20th of each month starting Month:_______ Year:_______
as per the Terms and Conditions below.

ACCOUNT NUMBER ________ _______ _______ _______ Expiry _____/______

Name on card: _____________________________________

Terms and Conditions (as suggested by NCF's bank)

I/We will notify National Capital FreeNet Incorporated in writing of any changes in the account information or termination of this authorization at least thirty (30) days prior to the next payment date.
MY/OUR financial institution will treat each debit as if I/We had personally issued a written direction authorizing National Capital FreeNet Incorporated to debit the amount specified to my/our account and need not verify that payments are drawn in accordance with this authorization.
I/We understand that any debits charged to my/our account will be reimbursed if:
(a) this debit was not drawn in accordance with this authorization;
(b) this authorization has been terminated; or
(c) the debit was posted to the wrong account due to invalid/incorrect account information supplied by National Capital FreeNet Incorporated, by giving notice in writing to my/our branch of account within ninety (90) days of the debit to my/our account.
I/We acknowledge that delivery of this authorization to National Capital FreeNet Incorporated constitutes delivery to my financial institution.
I/We warrant that all persons whose signatures are required to sign upon this account have signed this authorization.