You fill in this form if you want your Membership Fee and/or Training Fee automatically deducted from your credit card when they fall due. This is a very efficient means for us to take care of your payments. If you do not complete it, we will bill you by ordinary mail. Print the form to fill it out, then send it to us. NAME:________________________________________________________________________ ADDRESS: (Street)___________________________________(City)______________________ (State)____________________(Country)___________________ (Post/Zip Code)____________ TELEPHONE: (Home) (_______)_________________ (Work) (_______)__________________ FACSIMILE: (_______)___________________ Email:_________________________________ URL: __________________________________________ I agree with the Biame Network Inc. that it may use my credit card to pay the fee(s), as set out below, every year, until I contact the Biame Network Inc. and change this arrangement. I understand that these fees may change from time to time and agree to pay whatever the fee is at the time it is levied. I understand that it is my responsibility to contact Biame Network if I ever want this arrangement changed in any way. [__] Annual Membership Fee (Currently: $55.00 p.a. ) [__] Annual Training Fee (Currently: $50.00 p.a.) (tick one or both boxes as appropriate) by credit card in accordance with the above declaration. Use the following credit card: Credit Card Number: Telephone: 1800 244 254 (Freecall in Australia); +61 3 5799 1198 (International) Facsimile: +61 3 5799 1132 Email: biamenet@eck.net.au Website - http://www.biamenetwork.net |