VOICEGATE CREDIT CARD AUTHORIZATION FORM

Name: ________________________________________________________________________________

(First Name) ( Last Name)

Company Name: ________________________________________________________________________

Address: _______________________________________________________________________________

Phone#: ______________________________________ Fax#: ________________________________

As part of this agreement, ”Customer”/Cardholder authorizes VoiceGate Corporation to charge for said product/

service on the credit card information indicated below:

Credit Card: (Please Circle) Visa MasterCard American Express

Credit Card Number: ___________________________________________ Expiry Date: _____________

Cardholder Name: _______________________________________________________________________

I,________________________, have been authorized to make purchases for “Customer” and am an authorized

(Authorized Signer)

signer on “Card”.

This “Card” authorization will apply and be legally binding for any future orders (written or verbal) placed by “Customer” via phone, fax, e-mail, or any other means. In addition to the aforementioned card signer, the

following individuals may place orders on “Customer’s behalf”:

_____________________ ______________________ _____________________

(Name) (Name) (Name)

_____________________ ______________________ _____________________

(Signature) (Signature) (Signature)

and I understand all charges will be applied to the aforementioned credit card.

Should “Customer” choose to revoke such “Card” authorization, he/she must do so in writing, with said revocation

taking place within ten business days of receipt of said notification.

Written notification is to be sent to:

VoiceGate Corporation, 163 Rivalda Road North York ,Ontario M9M 2M7

Signature:__________________________________________ Date: ________________________

Thank you for your patronage. VoiceGate is committed to providing the highest quality service available in the market place. Prepaid technical support hours are from Monday to Friday 9am – 5pm EST. Unused prepaid tech

Support time is valid for 6 months.