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  Customer Application Form
  Service order/ price quote form
  Proxy Radius Setup Form
  Credit Card Authorization
 
 
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MODEM POPS
6776 Southwest Freeway # 600, Houston TX 77074
Ph: 832-615-3240 /  Fax: 713-787-0675
 
Credit Card Authorization
(Please fax the completed form to us)
       
  Company Name  
  Name Of Card Holder  
  Phone Number - -  
  Billing Address Of Card
Street and Suite No.
  
  City      
  State      
  Zip Code      
  Card Type :
(Visa, MasterCard, American Express)
  
  Account Number :
 
  3-digit Security Code 
 
  Expiration Date : (Month/Year)
  
  I hereby authorize ModemPops to initiate debit entries to my (our) credit card Account, as mentioned above.  This authority is to remain in full force and effect until ModemPops has received written notification from me (us) of its termination in such a time and manner as to afford ModemPops a reasonable opportunity to act on it.  
 
Print Name
Date
 
 
 
 
All ModemPops services are provided under the terms of the ModemPops Service and License Agreement.
  

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