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    Credit Card Authorization Form 

    Please Print And Complete This Authorization And Return To 
    Canada Relink/Call2Talk 
    Fax # 519-250-4055
    All Information submitted is Confidential. 


    Cardholder Full Name: _____________________________________________


    Billing Address:___________________________________________________


    Credit Card Type:  _______ Visa ______ Mastercard ______ Amex


    Credit Card Number:______________________________________________



    Expiration Date: _____________      CVS# __________



    Amount To Charge: $________ for Monthly Services plus taxes and credit card surchage.

    Amount to charge: $_______ to load my account for Collect Calls + taxes and credit card surcharge 

    I,(the customer) Authorize Canada Relink/Call2Talk to charge my credit card with the agreed amount listed above to my credit card provided therein. I agree that I will pay for this purchase in accordance with the issuing of the Bankholder agreement:
    The Customer must call in everytime to notify Canada Relink/Call2Talk to charge the card. There will be a credit card fee charged for every transaction. The customer must provide Canada Relink with a signed authorization form to charge the credit card. If this pre-authorized form is not signed and dated by the customer, Canada Relink does not have the authorization to charge the credit card and the customer forfeits their rights for the service.


    Cardholder-Please print name, Sign and Date Below:


    Full Name:_____________________________________________


    Date: _____________________________________________


    Signature: _____________________________________________



    Once Signed Please Return the original completed form to:

    Canada Relink
    Accounting Department 
    Fax # 519-250-4055
    6642 Tecumseh Road East 
    Windsor ontario 
    N8T 1E6

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