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Pre-Authorized Payment Authorization Form

Sentex Data Communications        http://www.sentex.ca
240 Holiday Inn Drive Unit D, Cambridge Ont, N3C 2X4
Support: (519)51-3400 Fax: (519)651-2215

Please complete this authorization form and include one of your personal cheques marked void and return it with this form.

To: Sentex Communications Corporation

Your Name as it appears on the cheque:

Address:

Town/City:                                                                                                                                                    Postal Code:

Name of Financial Institution:

Branch Address:

City:                                                                                                                                                               Postal Code:

Bank Number:

Transit Number:

Account Number:

I/We (the above named customer) authorize Sentex Communications to debit my/our account indicated above, in the amount of $_______ on the 1st day of each month, for payments payable to the company in respect of the Personal Preference Package of Internet services. Each payment shall be the same as if I/we had personally issued a cheque authorizing the bank to pay Sentex Communications as indicated and to debit the amount specified to my/our account. I/we will notify Sentex promptly in writing if I/we move the account from one branch to another, or if there is any other change in the account.

I/we understand that the bank is not responsible to verify whether the payments are properly debited to my/our account. This authorization may be canceled at any time with 30 days written notice from me/us to Sentex. I/we understand that if we cancel this authorization, it does not mean that our contract obligations to Sentex are ended.

Any delivery of this authorization to Sentex constitutes delivery by me/us to the Bank.
I/we am/are all the persons who are required to sign on the above accounts.
I/we have received a signed copy of this authorization form.

Date  ________________________          Customer Signature______________________________________

Date  ________________________          Customer Signature______________________________________

Please complete information, sign document, attach a VOID CHEQUE

And return to Sentex Communications within 10 days.

Office Use Only                  User ID:                                                                     Amount:                                                  Date: