AutoPay by Credit Card

Please fill out and return to the address below or return with your cable payment.

 

 TVMAX Processing Department
  10300 Westoffice Dr.
 

Suite 200

 

 Houston, TX 77042-5329

 

Customer Name

_____________________________________________________

Cable Account Number

______________________________________________

Service Address

____________________________________________________

City _______________________   State  ___________   Zip

_________________

Day of Month to Process Charge

_______________________________________

Cardholder Name

___________________________________________________

Card Number

_______________________________________________________

Expiration Date

_____________________________________________________

Card Type

_________________________________________________________

Card Address

______________________________________________________

Card Zip

___________________________________________________________

CHECK ALL THAT APPLY
TVMAX Cable Account Payment q Yes q No
TVMAX High Speed Internet Payment q Yes q No
BOTH TVMAX Cable and High Speed Internet Payment q Yes q No

 

I (we) authorize TVMAX to initiate debit entries to my (our) credit card account indicated above.

 

Signature ____________________________________ Date

_________________

 

It is your responsibility to update your credit card information with TVMAX whenever there is a change. This recurring authorization of payment will remain in effect until written notification is received by TVMAX to discontinue.

OFFICE USE ONLY
Process Date _________________________ Effective Date

_________________