Credit Card Authorization 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 if applicable to the service you select.Customer InformationNew or Existing Account*New accountUpdate CC of existing accountUpgrade/Downgrade existing accountCustomer Name* First Last Company NameCustomer Email* Phone*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 PhoneCommitment All information is kept confidential and used only for the purposes as noted above. All HUGHESNET accounts require a 24 month commitment. HUGHESNET Suspended months of service do not count toward fulfilling commitment agreed to. If payment is declined on the first of the month, the service will be suspended. Month to month HUGHESNET agreements may be subject to price increases. STARLINK is month to month Service. Suspensions must be emailed at least 2 days prior to end of month, or new cycle charges will apply and are non refundable Select a commitment*Update existing accounts billing information.Agree to month to month STARLINK serviceAgree to month to month HUGHESNET service. ($400.00 up front fee)Agree to 24 month HUGHESNET service commitment.If you cancel after activation before the end of a HUGHES 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.NameThis field is for validation purposes and should be left unchanged. Toggle Credit Card AuthorizationCustomer InformationPayment DetailsDealer InfoCommitment