Please print
out (or hand write if you do not have a printer) this agreement, sign (must be a person
who is authorized to sign card) and mail to :
CWIA
1731 Howe Ave. PMB364
Sacramento, Ca 95825
I agree that I have entered into an agreement with CWIA to provide me with internet access
and have agreed to pay for the following charges (check which ones):
___ Initial Charges
___ Monthly Automatic Billings (will be billed monthly on the first of the week of the
anniversary day).
___Monthly Charges (Email will be sent 2 weeks prior to due date and is due by anniversary
date either paid by check or this page filled out. Check payment is available to quarterly or longer accounts. Not available to usage based accounts).
for the account of :
Name: _______________________________
Address:________________________________________________________
with the following credit card:
Type of Card:___________________
Card Number: _____________________Exp. Date_____________
Name on Card:________________________
Billing Address:___________________________________________________
Bank:__________________________
I further agree that CWIA will have full defense of these charges if no complaints of
charges have been both registered US Postal mailed to above address and emailed to
acct@cwia.com within 15 days of billing date on statement from credit card bank.
Jurisdiction of any disputes of charges shall reside in the county of Sacramento, state of
California.
Signature:______________________________ Date:_______________
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