CCIA Change Billing Cycle 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) _____ MONTHLY ($20.00 a month) _____ QUARTERLY ($18.50 a month) _____ SIX MONTH ($17.00 a month) _____ YEARLY ($15.50 a month)

VISA * MASTER CARD * DISCOVER * AMERICAN EXPRESS (circle one) CARD #_____________________________________________EXP DATE__________ CARDHOLDER'S NAME _____________________________________ Computer Central will bill my credit card   $___________  monthly, $__________ quarterly, $__________ every six months, or $__________ yearly. PLEASE CHOOSE THE FOLLOWING PAYMENT TERMS. (check one) _____ MONTHLY ($20.00 a month) _____ QUARTERLY ($18.50 a month) _____ SIX MONTH ($17.00 a month) _____ YEARLY ($15.50 a month)

E-Mail Address (Please Print Neatly) _____________________________________@ccia.com

SIGNATURE X______________________________ DATE __________

By signing this form, the applicant gives Computer Central the permission to bill using the payment terms they have chosen for internet connectivity. Billing will continue without exception as stated in the billing policy 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