Pre-Authorized Payment Agreement - Exhibit C: Hawaii Information Service Agreements, Applications, Forms, Documents - real estate, property listings, multiple listing service for hawaii, public records, parcel maps, business registrations, professional and vocational licenses, digital subscriber lines

Hawaii Information Service
Pre-Authorized Payment Agreement - (Exhibit C)
Print this completed form, sign, and FAX it, along with Exhibit A and a
copy of your license to HIS at 888-628-3121 or 536-6499
(Or mail it to us, if you prefer)

PRE-AUTHORIZED PAYMENT AGREEMENT - (EXHIBIT C)

I authorize Hawaii Information Service (HIS) to keep my signature on file and to charge by VISA/Master Card or debit my checking/savings account for the following fees:

Training Reservation Fee (Applied to all Applicants) See Exhibt B - Schedule of Fees and Charges

The Initial Subscription Fee - See Exhit B - Schedule of Fees and Charges

Subscription Fee (Assessed in Advance) See Exhibit B - Schedule of Fees and Charges
Annual Semi-Annual ) Quarterly

Fees for Services incurred by Associate Subscriber (i.e., photographs, e-mail/Internet
access, quality control fees, etc.)See Exhibit B - Schedule of Fees & Charges

I understand that this form is valid so long as I am a SUBSCRIBER of HIS. To prevent service interruption, I will notify HIS of any change in my Credit Card or Checking/Savings account. I agree to abide by HIS Subscriber License & Access Agreement Section 6.3 which states: "Fees are non-refundable and will not be prorated".

Billing Address:
Billing City: Billing State: Billing Zip:
Email Address:

PLEASE SELECT ONLY ONE (1) PAYMENT OPTION:

Option #1 - Charge my Credit Card

Visa Mastercard Account#: Expir. Date:
Name:
(Please Print Name exactly as it appears on your credit card)

Signature:_________________________________________________ Date:___________________
This account information will be used for:
(Print Account Holder's name above, if other than the Associate Subscriber)

Option #2 - Debit my Bank Account

Checking (Attach a copy of a VOID check) Savings (Attach a copy of a Deposit Slip)
Bank Name: Branch:
City: State: Zip:
Name:
                  (Please print name exactly as it appears on your account)

Signature:_________________________________________________ Date:___________________
(Print Account Holder's name above, if other than the Associate Subscriber)

Option #3 - Check (Only for Annual Payment)

Checking (Attach a copy of a VOID check) Savings (Attach a copy of a Deposit Slip)
Bank Name: Branch:
City: State: Zip:
Name:
                  (Please print name exactly as it appears on your account)

Signature:_________________________________________________ Date:___________________
(Print Account Holder's name above, if other than the Associate Subscriber)

Option #4 - Office Billing (Only to be selected by the PB/DR)

Office Payment Cycle: Office Payment Method:
PB Name:

PB Signature:_______________________________________________ Date:___________________


Please fax this Exhibit C along with Exhibit A of the Subscription Agreement and a copy of your license to: 1-888-628-3121. (Or mail it to us, if you prefer.)

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