VISOX.COM Checking Account Debit
Authorization Form

VISOX.COM accepts automatic debit from checking accounts as payment option. To have your checking account debited VISOX.COM services we MUST have the following signed statement on file. Accounts will be charged on the invoice date.
All fields are required:

Name (as it appears on your checks):

_______________________________________________

Address (as it appears on your checks):

_______________________________________________

City: ________________State/Prov: ______Zip:________

Country:_________

Domain Name/Username: __________________________

Email Address: _______________________________________

Phone number:_______________________________________

Routing Number:______________________________________

Account Number:______________________________________

Starting Check Number:____________

(You can use any check number you wish to start. If you choose 2002 then the next month check will be 2003, etc so on. Hint: If you choose a number sequence that you are not currently using in your check book then it will easy to see which debit is from us because the check numbers will be totally out of sequence.)

I authorize VISOX.COM to debit my checking account for charges for VISOX.COM service that I may accrue from month to month or any past due balances in order to bring the account in current status. I further agree that I will not dispute (chargeback) these charges. This authorization is valid until revoked in writing.

Authorized signature: ___________________________________

This form MUST be either mailed or faxed to VISOX.COM  immediately in order for your account to be started on our servers. This process is included to protect both you and VISOX.COM. Debit charges will appear a regular check your statement payable to VISOX.COM

Fax to: 909.954.9570
or Mail to:

VISOX.COM
22365 Barton Road
Suite 309
Grand Terrace, CA  92313