I.A.S.- Intercommunication American Systems, Inc.

AGENT NO.: __ID# 5605__________________

SUBSCRIBER’S CREDIT CARD INFORMATION BILLING INFORMATION

Subscriber :	Bill to:
Street Address:	Street Address:
Street Address:	Street Address:
City, Postal Code, Country:	City, Postal Code:
Telephone Number / Fax Number:	Country:
Primary contact person and title:	ACCOUNT NO.: __________________

The Subscriber named above (Subscriber) and Intercommunication American Systems, Inc. (I.A.S.) agrees to provide and the Subscriber agrees to pay for all services rendered by I.A.S. The Subscriber further agrees to use the I.A.S. services in accordance with the instructions provided and, by signing below, acknowledges that he/she has read, understands and agrees to the terms of this contract.

ITEM	CUSTOMER CALLBACK NUMBER TELEPHONE NUMBER	ACCESS NUMBER ASSIGNED	CREDIT LIMIT	EXTENSION	LANGUAGE

AUTHORIZATION

I (we) do hereby authorize Intercommunications American Systems, Inc. (IAS) to charge my credit card / bank account listed below for the amount listed above, for the amount of total monthly usage or each time my bill reaches a usage amount of $250.00. In this case, at the end of the month, I (we) will be charged any remaining balance to equal the monthly invoice which will be mailed to me/us for our records. In the event that this credit card becomes invalid, I (we) shall be responsible for all outstanding charges. This authorization is to remain in effect until Intercomunication American Systems, Inc. receives written notification from the undersigned to cancel this authorization. Charges will be made in the name of I.A.S.

Authorization for Automatic Bank Payments Authorization for Automatic Credit Card Payments

Signature________________________ Date________________

____________________________________________________
Bank or Credit Institution Bank Number

____________________________________________________
City Province/Country Zip Code

___________________________________________________
Account Number

Checking o Savings o

Attach Voided Check

VISA/ MASTERCARD o JCB o AMEX o DINERS o

__________________________________________________
Cardholder's Signature Date

__________________________________________________
Name on Card

__________________________________________________
Card Number Exp Date (Month/Year)

Attach:
1. Photocopy of the front & back of your Credit Card
2. Photo I.D. for address verification.

( IMPORTANT: MUST MATCH SUBSCRIBER INFORMATION )

This Agreement must be signed by the suscriber and original sent to I.A.S.

Applicant understands that IAS Film Corp. may use this information
to obtain credit bureau reports as IAS deems necessary or desirable.

_______________________________________

Date of Birth:

______________________________________

Subscriber Name:

______________________________________

Title:

______________________________________

Signature of Subscriber:

______________________________________

Date:

______________________________________

2875 Northeast 191st Street, Suite 603, Aventura, Florida 33180 l Fax 1-831-688-2834,,,,7920# l E-mail: [email protected]