COMPUTER CENTRAL WEB MAIL BILLING AUTHORIZATION
1014 Third Avenue New Brighton, Pa. 15066 Voice (724)-846-3063 Fax (724)-846-0423
8 East Washington St. New Castle, Pa. 16101 Voice (724)-658-8744 Fax (724)-658-7268

1. Applicant Information

NAME: _____________________________________________________

ADDRESS: ____________________________________________________

CITY: _____________________________ STATE: ______ ZIP: ________________

WORK PHONE___________________ HOME PHONE ___________________

Referred by _____________________________________(Please Print)

2. Subscription Type

CCIA.COM offers Web Mail email accounts to all internet users.

I hereby request Computer Central to subscribe me to the email address(es) I have chosen.

PLEASE COMPLETE THE FOLLOWING FORM (Please Print)

Your current email address ____________________________________

_____ # OF Web Mail E-Mail Address Requested

Requested e-mail name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __@ccia.net
 
Password __ __ __ __ __ __ __ __ __ __
 
Requested e-mail name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __@ccia.net
 
Password __ __ __ __ __ __ __ __ __ __

 
(20 Character limit On E-mail Address, And a 10 Character limit On Passwords.)

Applicant’s Signature X______________________________ DATE ______________

Applicant’s Name ______________________________ (Please Print)

 
 
Billing Authorzation Form

I authorize Computer Central to accept the method of payment that I have chosen.

You only need to fill out one BOX.
 
CASH  *  CHECK  *  MONEY ORDER (circle one)

PLEASE CHOOSE THE FOLLOWING PAYMENT TERMS   (check one)

_____ QUARTERLY ($15.00 + $5.00 one time setup fee)
_____ SIX MONTH ($30.00 + $5.00 one time setup fee)
_____ YEARLY ($60.00 + $5.00 one time setup fee)

VISA * MASTER CARD * DISCOVER * AMERICAN EXPRESS (circle one)
CARD #_____________________________________________EXP DATE__________

CARDHOLDER'S NAME _____________________________________

Computer Central will bill my credit card   $___________  setup fee, $__________ quarterly, $__________ every six months, or $__________ yearly.


PLEASE CHOOSE THE FOLLOWING PAYMENT TERMS. (check one)

_____ QUARTERLY ($15.00 + $5.00 one time setup fee)
_____ SIX MONTH ($30.00 + $5.00 one time setup fee)
_____ YEARLY ($60.00 + $5.00 one time setup fee)

Applicant’s Signature X______________________________ DATE ______________

Applicant’s Name ______________________________(Please Print)

By signing this form, the applicant gives Computer Central the permission to bill using the payment terms they have chosen for Web Mail. Billing will continue without exception as stated in the Terms Of Service until cancellation is received in writing with a signature by Computer Central prior to the next billing period.

Print this form out, and mail it to:

Computer Central
8 East Washington Street
New Castle, PA 16101
Or Fax:

724-658-7268