Please PRINT THIS FORM and FAX IT TO US along with a copy of your VOIDED CHECK to: 253-848-0848.

AUTHORIZATION TO DO AUTOMATIC CHECK DRAFTING

Company Name: ______________________________________

Contact Name: ________________________________________

Account UserName: ____________________________(if known)

Bank Name: __________________________________________

Account Number: ______________________________________

Routing Number : ______________________________________

Fraction Code : ________________________________________

I authorize Stealth Media Solutions to use automatic check drafting as the method of payment for services received through their company. I realize that no signature is required on these checks and that if I dispute a charge through my bank this will constitute a breach of contract and will result in the immediate cancellation of my Internet services. Dishonored checks are subject to a collection fee of $25 and User's account may be suspended until the account is current. If payment is not received within five (5) days of the due date, service will be terminated and a re-connect setup fee of $14.95 will be added to charges for additional Service.

I have included a blank voided check along with the signed copy of this automatic check drafting authorization form.

Signature: _______________________________________

Date: _________________

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