Meta3 * Network-One * TILC * Net-2000 * Netreliance

Customer Information

Ayrix Account Number		Email Address		User Name
List Any Additional Email Addresses
Name (First, Last)
Address
City		State		ZIP
Home Phone		Work Phone		Fax

Financial Institution Information

Name On Account
Financial Institution Name		Branch
City		State		ZIP
Routing Number (1st nine digits)		Account Number

I hereby authorize Ayrix Technologies, Inc. (d/b/a Big Net) to pay my monthly Internet services account by charging each payment to my bank account and to make that deduction payable to the order of Ayrix Technologies, Inc. I agree that each payment shall be the same as if it were personally signed by me. This authority is to remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution and Ayrix Technologies. Ayrix reserves the right to terminate this payment plan or my participation therein if services are cancelled.

Please return this completed authorization form and a VOIDED check from the appropriate account to:

P.O. Box 28
Ripley, MS 38663
(662) 993-2000   (800) 918-9023
FAX (662) 993-2001