Payment Authorization

Please complete the form below to place a payment method on file for your monthly maintenance service. Your details are transmitted over a secure, encrypted connection. Questions? Reach us anytime:

Monday – Friday 9am – 6pm (888) 792-2550 Opt 2 billing@networkintelligence.net

Agreement

Date

Business / Entity Name

I authorize Network Intelligence, LLC. to charge the credit card indicated below for services in the amount provided below, plus mileage and any other charges agreed with the customer, each billing period prior to service. I have read and agree to the above authorization, and I confirm I am an authorized signer for this account.

Authorizing Person (full name)

Billable Amount (USD)

Customer

Customer Name

Phone Number

Email Address

Location

Location Name

Location Phone

Street

City

State

ZIP

Site Point of Contact

Site PoC

PoC Phone Number

PoC Email Address

Payment Method

Card Holder

Card Number

Expires

•••

CVV

Security Code (CVV)

Card Billing Address

City

State

ZIP

Your card details are sent only to Network Intelligence over an encrypted connection and are never stored in your browser.

Authorization Signature

Sign below to authorize this recurring charge

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