Indian Creek Internet

INDIAN CREEK INTERNET SERVICES, Inc.

Authorization for Direct Payment Automatic Bill Payment Company Name Indian Creek Internet Services, Inc. (the "Company). I (we) authorize the Company to initiate variable entries into my (our) account described below:
Checking Account No. _________________	Savings Account No. ______________
Financial Institution's Name _________________________________________________
Finanacial Institution's Address ______________________________________________
Attach a voided check, savings deposit slip (below). On what date would you like your account to be debited? 1st _______ 15th _______ This authority is to remain in full force and effect until the Company has received written notification from an authorized individual of its termination in such time and manner as to afford the Company a reasonable opportunity to act on it.
Individual	(Optional - for Joint Account)
Signature: _______________________	Signature: ___________________________
Full Name: _______________________	Full Name: __________________________
Address: _______________________	Address: ___________________________
Date: __________________________	Date: ___________________________
Telephone No. _______________________	Telephone No. _______________________

Business
Company Name: ________________________
By: __________________________________
Name: ________________________________
Title: __________________________________
Date: _________________________________