Service & Payment Authorization Form
Please fill out this form and fax to 1-425-702-8758
(backup fax# 1-425-702-9151).If
your payment method is approved, your order will be activated in 48 hours
and you will receive your instructions by Fax# provided.
REQUIRED: ALL customers must fill
in Main Online
Order form & fax in this page for order to be accepted!
Name: (Organization/individual person)................................................................................................
Address:......................................................................City:...........................................................
Contact person:................................................................................................................................
Contact Phone......................................... Contact Fax...............................................
Method of payment: (ensures on-time payment)
Credit Card: Write all numbers, including expiration date.
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Credit Card Number:.....................................................................
Expiration Date: ...........................
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Name Cardholder: .......................................................Signature:....................................................
Authorization for Auto Bank Debit
NOTE: Bank debit payment is acceptable if your bank is located
in one of the following countries:
Austria, Australia, Belgium, Denmark, Finland,France, Germany, Greece,
Hong Kong, Ireland, Italy, Japan, Netherlands, NewZeland, Norway, Portugal,
Spain, Sweden, Switzerland, UK or USA.
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Bank Name: ........................................................Bank
Account Number:............................................
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Bank Address.....................................................................Bank
Phone..........................................
-
Bank Code..................................
Undersigned Customer hereby requests Global Access international
long distance service(s) from Telegroup. If this service order is granted
and either credit card or bank debit is the payment method, Customer authorizes
Telegroup to either charge the above-listed credit card number or automatically
debit the above-listed bank account for all charges attributableto 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 Acces CallBack
Minimum Policy and agrees to cover the charges it specifies; that the Customer
further acknowledges that the Policy is subject to change. If the customer
orders Dialers, the customer (a) acknowledges the Telegroup Technologies
dialer(s) are leased to the customer for specific use with Telegroup Services
only (b)authorizes the Telegroup Technologies Programming & Provisioning
fee to be charged to their Telegroup account. All our transactions are
subject to our General Conditions, which will be sent to you at your request.Name/Title
- Please Print.................................................
Authorized Signature............................................
Date....................................
[Telegroup Main Svcs. Page] [Main
Online Order form]