POND SMART SIM INTERNET SERVICE ORDER FORM
Customer Information
Customer Name
*
First Name
Last Name
Business / Organization (if any)
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Plan
5 GB (For 1 Station) – $49 / month
10GB Plan (For 2 Stations) – $59 / month
20GB Plan (For 2 or More Stations) – $69 / month
40GB Plan (For 3 or more Stations with high traffic) – $129 / month
Other / Notes
RECURRING ACH PAYMENT AUTHORIZATION
Bank Holder Name
*
Bank Name
*
Routing Number
*
Account Number
*
Account Type
*
Checking
Savings
Authorization for Recurring Payments:
I authorize Pond Smart / ST Unlimited LLC to debit the account listed above for: Monthly SIM ISP service charges and Applicable taxes and fees
Frequency: Monthly
Start Date
*
-
Month
-
Day
Year
Date
Maximum Monthly Amount Authorized:
Term
Customer Signature for ACH Authorization
*
This authorization remains in effect until written notice is provided at least 10 days before the next scheduled payment.
Signature Date
*
-
Month
-
Day
Year
Date
Customer Authorization for Service
*
I authorize activation of the Pond Smart SIM ISP service and confirm that all provided information is accurate.
Authorization Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: