CC Credit Card Authorization By completing and submitting this form, you give Houston Media Systems permission to make monthly charges to your account for the amount indicated starting on or after the indicated date. This is permission for a single, monthly recurring transaction only, and does not provide authorization for any additional unrelated debits or credits to your account other than the ETF stated on this authorization.Customer InformationNew or Existing Account*New accountUpdate CC of existing accountUpgrade/Downgrade/VOIP Service of existing accountYour SAN# if updating existing billing informationCustomer Name* First Last Customer Email* Company NamePhone*Payment DetailsCredit Card*We do not accept American ExpressVISAMasterCardDiscoverMonthly Payment*Credit Card Number*Expiration Date*MM/YYCardholder's Name* First Last Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Digital Signature*Please type your name below to digitally sign this form, authorizing us process your credit card.Date* Dealer InfoDealer NameDealer Email Dealer PhoneCommitmentSelect a commitment*Agree to 24 month Gen5 service commitmentAgree to 18 month HN service commitmentHN Month to month commitment $400.00 up front feeGen5 Month to month commitment $400.00 up front feeAgree to 12 month HX service commitmentUpdating existing accounts billing informationAgree to 24 month Hughes Voice service commitment All information is kept confidential and used only for the purposes as noted above. All HX accounts require a 12 month commitment. All Gen5 accounts require a 24 month commitment. Suspended months of service do not count toward fulfilling commitment agreed to. If billing is suspended and reactivated within 25 days, a $25.00 fee will be charged. If payment is declined on the first of the month, the account will be suspended. Month to month commitments are not available in Cuba. Month to month agreements may be subject to price increases. If you cancel after activation before the end of a Gen5 24-month term commitment, you will be charged a Service Termination Fee of up to $415. The exact amount of the Service Termination Fee will be $415 for the first ninety (90) days after activation of the HughesNet Service. Thereafter, the amount will decrease by $15 per month for each full month of active Service.EmailThis field is for validation purposes and should be left unchanged.