Automatic Recharge Stoppage

I, the undersigned, being the person whose name appears on the credit card below, request that Base Telecom Inc. stop recharging my account with my credit card.

Please, fill this form or send by fax: 1-905-850-4642

	Account holder's name       Ani/Travel/ PIN Number       Invoice Number       Amount of Recharge   ------------- $10 $15 $20 $25 $30 $40 $50 $100     » Credit Card Information      Name (As seen on front of the card)       Choose Currency (USD or CAD)   ------------- USD CAD     Choose Card Type   ------------- VISA Master Card American Express     Card Number   Security Code:     Expiry Date   Month 01 02 03 04 05 06 07 08 09 10 11 12       » Personal Information      First and last name       Contact phone       Email       FAX       Street Address       City   Province/State

I understand that when the Subscription account reaches the minimum balance I have chosen, the Subscription account will be automatically replenished at 4:00A.M. EST the following day. Therefore there maybe instances where the account reaches a zero balance and the automatic recharge will not be processed until 4:00A.M. EST.

Please note: You can also choose to use your credit card to recharge your account, at any time, by calling customer service at 1-905-xxx-xxxx or through the web at www.basetelecom.net