CC - Houston Media Systems

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 Information
New or Existing Account*
Customer Name*
First Last
Company Name
Customer Email*
Phone*
Payment Details
Credit Card*
We do not accept American Express
- VISA
- MasterCard
- Discover
Monthly Payment*
Credit Card Number*
Expiration Date*
MM/YY
Cardholder's Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Digital Signature*
Please type your name below to digitally sign this form, authorizing us process your credit card.
Date*
Dealer Info
Dealer Name
Dealer Email
Dealer Phone
Commitment
Select a commitment*
1. All information is kept confidential and used only for the purposes as noted above.
2. All Gen5 accounts require a 24 month commitment.
3. Suspended months of service do not count toward fulfilling commitment agreed to.
4. If payment is declined on the first of the month, the account will be suspended.
5. 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.
Email
This field is for validation purposes and should be left unchanged.

Credit Card Authorization

Customer Information

Payment Details

Dealer Info

Commitment