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WVNET Modem Account Billing
Credit/Debit Card Payment Authorization Form

This form will authorize WVNET to charge your credit card or debit card (i.e. Visa check card) for your monthly service. Please call 304.293.5192 x 258 or 253 if you have any questions or changes.

Please print this form and mail or fax it to:

WVNET
ATTN: Libby Cress
837 Chestnut Ridge Rd.
Morgantown, WV 26505
Fax Number:
 304.293.5540
Contact Information (* denotes mandatory field)
* User ID/Account ID
(i.e.abc00001)
 ______________________________
*First Name
 ______________________________ *Last Name______________________________
*Address
 ______________________________
______________________________
*City
 ___________________ *State_____ *Zip _________
*Phone
 ____________________
Fax
 ____________________
Email Address
 ______________________________________
Method of Payment
We accept Visa, MC, Discover, AMEX.
*Credit/Debit Card Type
(Please choose one)

______Visa ______Mastercard
______Discover ______American Express
*Cardholder's Name
 ________________________________
*Credit/Debit Card Number
 ________________________________
*Expiration Date
(mm/yy)
 _____/_____
Amount to be billed: $16.95/month


*Cardholder's Signature:_______________________________________________