Billing address:
(If
different from Service address)
(Company)
Address
Name Mr Mrs Ms
City
Last name (Surname)
State/Province
Address
(No PO
box)
Postal
Code
City
Country
State/Province
Service Ph.
Postal Code
Service Fax
Country
Email
GA800: US toll free number(s) should
ring on telephone: (Please include Country code)
Same
as service phone & service fax
Additional service available:
Spectra
Prefix
GA-Direct
CallBack
- Mobilephone
CallBack
- Home/office
Calling
Card(s)
Number of cards:
Requested limit ea. card:
Authorization & Letter of Agency
(LOA)
Undersigned Customer hereby requests
Global Access™ international long distance service(s). If
this service order is granted and either credit card or bank debit is the
payment method, Customer authorizes Telegroup to either charge the below-listed
credit card number or automatically debit the below-listed bank account
for all charges attributable to the services ordered. If credit card billing
is selected, the undersigned understands that the same terms and conditions
normally governing the use of the credit card apply to this use as well.
Customer authorizes Telegroup and its agents to perform credit checks and
to investigate the bank references and other credit or financial information
or references submitted to Telegroup, where permitted. The undersigned
represents that he/she has authority to request Global Access service(s)
for the Customer, that the Customer understands rates are subject to change
without notice, that the Customer acknowledges that Telegroup Agent has
informed Customer of the Global Access CallBack Minimum Policy in effect;
that the Customer understands the Policy and agrees to cover the charges
it specifies; that the Customer further acknowledges that the Policy is
subject to change. All our transactions are subject to our General Conditions,
which will be sent to you at your request. USD 20 MONTHLY FEE APPLIES TO GA-800.
Does not apply to other services.
Form of payment
Debit
my credit card.
Account #:
Name on card:
VISA MC
or EUROCARD
AMEX DISCOVER
Expires:
MO:10
YR:
Credit card authorization
.
Authorized Signature:_______________________________
Date:_______/_______/_______.
.
Mail to: Affinity Telecom, PO BOX
674, S-64559 STRANGNAS, SWEDEN
or fax to: +1-305-574-6143 Phone: +1-877-689-2259
E-Mail:ga800@affinity-telecom.com
Credit card authorization