Skywiz Internet Services
7400-20 Ave.
Brooklyn, New York 11204
Customer Information(Bill to):
Name/Contact:_______________________________________________________
Company/Dept:_______________________________________________________
Address:____________________________________________________________
City:_________________State__________Zip___________Email____________
Home phone___________________Business phone_____________Fax_________
Payment Information
Method of payment:_____Credit card_____Check_____Cash_____Money order
Name on credit card_______________________Billing Address________________
Account number_________________________Expiration date_________________
Signature________________________________________date_______________
This agreement between Skywiz Internet Services and_____________________________
is for a period of 12 months at a rate of only 34.95 per month.
one time setup=59.95
34.95 X 12= 419.40
Total=479.35