AUTO DEBIT ENROLLMENT FORM

I, _____________ am authorizing CONVERGE ICT SOLUTIONS, INC. to charge my

credit card as payment for the Internet Subscription for this account:

Account No.

Account Name:
Contact Number of Account Holder:

Below are my terms and conditions:

Amount to be charged (MSF): _P1,500

*Pro-rated bills (if any) will be charged
*Amount to be charged will base on the outstanding balance. Hence, any changes made in the
monthly subscription fee due to transactions such as but not limited to: change package,
additional extension, etc. will reflect in the amount to be charged

Start Date: (month) FEBRUARY- (day) 05 - (year) 2020 End Date: FEBRUARY 05 2021
*Date of deduction is every 25th of the month
*Auto charge will be automatically cancelled if the card was declined for 3 consecutive months
*Any incurred penalty due to an unsuccessful charging of credit card shall not be waived
*An SMS notification will be sent to the mobile number indicated in this application form
for any unsuccessful transaction

Below is my Credit Card information:

Visa Mastercard American Express JBC

Credit Card Number –
Expiry Date – 03/23
*Auto charge will be automatically cancelled on the indicated expiry date

Signature over Printed Name Date

of the Credit Card Holder
Contact Number of cardholder: 09209005645

_______________________________
Signature over Printed Name of
Converge’s Authorized Representative