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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