Print this Form and Fax to PCI (Colorado Springs 719/572-5705)

ROAMING PAYMENT AUTHORIZATION

Service: The roaming software service is billed from the first of the month to the end of the month. You must have a credit card number on file with PCI Systems Inc. to use the service. Costs vary per hour depending on the location that you are dialing from. Please download the Ipass software for a list of dialing locations and charges. These additional charges will be charged to your account at the end of every month.

Cancel Policy: Cancels must be received by the 6^th to receive a refund for that month.

I/We authorize PCI Systems Inc. to charge our credit card account for the charges I/we iccur using the IPASS ROAMING SOFTWARE.

Credit Card Type (circle one): VISA Mastercard Discover AMEX

Credit Card Number: _______________________________

Exp Date: _________

Userid:_________________________

Name: ________________________________

Signature: _________________________________

(date)________________

Address: ___________________________________

___________________________________________

Phone:_____________________________________