Please fill out the form below. Once completed, print and sign the form, then send it to:
Cash Applications, P.O. Box 707, Lawrence, KS 66044-0707

	Automatic Payment Authorization
Customer #	Today's Date (mm/dd/yyyy)
Customer Name
Customer Address	Phone
Billing Address (if different from above)	Phone

I (we) , authorize my (our) bank to make my (our) payment by the method indicated below, and post it to my (our) account

(Please check one): Monthly Quarterly

I (we) hereby authorize Protection One Alarm Monitoring, Inc. to initiate debit entries in accordance with the payment schedule shown above to my Checking Account/Savings Account or Credit Card indicated below at the depository financial institution named below, or Credit Card selected below, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Checking Account No. (attach voided check):	Routing No.:
Savings Account No. (attached voided deposit slip):	Routing No.:
Bank Name:
Address:
City:	State:		ZIP code:
Credit Card No.:		Exp. Date:
Name on Card:

Card Type: VISA MASTERCARD AMERICAN EXPRESS DISCOVER

I (we) understand that I (we) am (are) in full control of my (our) payment, and if at any time I (we) decide to discontinue, I (we) will write the above named company, and I (we) understand the terms listed below.

Protection One offers a recurring fixed payment program. Protection One will send me (us) a letter advising of the date my (our) payment for the payment schedule will be deducted. After that, because the payments are the same each time, I (we) will not receive an invoice or statement. If the payment amount or payment date changes, I (we) will be notified of the change at least ten (10) days prior to my (our) bank account/credit card being debited.

This authorization is to remain in full force and effect until Protection One has received written notification from me (us) of its termination, which must be ten (10) days prior to the scheduled payment date to discontinue automatic payment service. Also, after the account has been charged, I (we) understand that I (we) have the right to have the amount of an erroneous debit immediately credited to my (our) account by my (our) financial institution up to fifteen (15) days following issuance of statement or forty-five (45) days after the account is charged, whichever comes first. I (we) understand that it may take up to three (3) months, after this authorization has been signed, for automatic withdrawals to begin, and I (we) may be billed by Protection One directly until such time.

Return Completed form to: Cash Applications, P.O. Box 707, Lawrence, KS 66044-0707

Customer #

Customer Signature:	Date Signed:
Customer Signature:	Date Signed:

Protection One Licenses: Pro One is regulated by: ALABAMA: Electronic Security Board of Licensure, 7956 Vaughn Road, Suite 392, Montgomery, AL 36116, Telephone 334/264-9332. License Numbers: AL #643, #533, #735, # 744, #1874, #28211; AZ #ROC086803, #ROC086819; AR # E97-122; CA #ACO-3717, #3241, #626615; CT185782; DE #1998200138, #97-54; FL #EF0001010, EF-A001010; GA #LVA001233; ID #SC21391, SJ22133, # SJ21419; IL #127-001000 #128-000174, #128-000151, #128-000115, #124-000195; LA #BF323, #D539, #7841, B3263; ME #MC60017582, MS60004713; MD #107-423, #3806266; MA #1574C; MI #36903202288, #3602203841,# A-0378,# 5103229,# 5201789,# 5201100,# A-0482; MN #CC00917; MT #299FPC, #6982CS; NV #0031668A, #F189; NM #58345; NY #12000261120 (Licensed by the NYS Department of State); NC # 24466-SP-LV, #1285-CSA; OH #53-18-1493; OK #621, #2817, #275, #2263; OR #116325, #34-428CLE; RI #9775; SC #BA5097, #FA3162 #BAQ2032; TN #641, #642, #697, #1037, #919, #512 # 00049692; TX #ACR-1637, #B-08690 #B-08702, #B-09792; UT #330634-6501, 5157013-6502; VA #11-2533; WA #GC983NO, #PROTE0022K2, #PROTEOAO33BP; #UBI601354926; WV #48694; WY #LV A 17, #TLV A 31.

Form # BD354.1 11/18/2002