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 transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

  • Customer Information

  • Payment Details

  • We do not accept American Express
  • MM/YY
  • Please type your name below to digitally sign this form, authorizing us process your credit card.
  • Dealer Info

  • Commitment

    1. All information is kept confidential and used only for the purposes as noted above.
    2. All HX accounts require a 12 month commitment.
    3. All Gen5 accounts require a 24 month commitment.
    4. Suspended months of service do not count toward fulfilling commitment agreed to.
    5. If billing is suspended and reactivated within 25 days, a $25.00 fee will be charged.
    6. If payment is declined on the first of the month, the account will be suspended.
    7. Month to month commitments are not available in Cuba.
    8. Month to month agreements may be subject to price increases.
  • This field is for validation purposes and should be left unchanged.