Cybercon Credit Card Authorization Form

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* Customer ID:___________________________________________________________________________

* Company Name:__________________________________________________________________________

* Contact Name:__________________________________________________________________________

* Credit Card Type: _ Visa, _ Mastercard, _AMEX, _ Discover, _ Dinners Club

* Credit Card #:__________________________ Security Code:_________

* Card Expiration Month (mm):_________     Expiration Year (yyyy):__________

* Is it a Debit card?  _ No.  _ Yes

* Cardholder First Name:__________________ Last Name:_______________________

* Card billing Street Address:
        City:_____________________________ State:___________________________
        Country:__________________________ Zipcode:_________________________

* Does the cardholder authorize for recurring charge in the future?
  (a) if yes, please check here: ____
  (b) if no, please specify the U.S. dollar amount that you authorize for: _________

* Credit card issuing bank phone number:____________________________________

* The cardholder agrees that Cybercon will automatically bill the subscriber's 
credit card each term specified above until the subscriber notifies Cybercon in 
writing to either cancel the account or stop credit card billing 30 DAYS prior 
to the first day of the month. Otherwise, cardholder will be responsible for 
current month service payment.  Customer shall provide notification of its 
termination of the Service by sending such notification via the web form 
at or certified United States Postal Mail, postage prepaid.

* Cardholder signature (MUST BE IN HAND WRITING):

* Date signed:

Thank you for your cooperation & your business.

Please fax this form to: 1.314.241.1777. Or postal mail it to:

210 N Tucker Bvld,
Suite 700
St. Louis, MO 63101

We thank you for your business.