International Long Distance Service Agreement

 

Customer Information:

First:

MI:

Last:

Title:

Organization:

Address 1:

Address 2:

Home Phone:

Fax Phone:

Work Phone:

E-mail:

Web Address:

 

Payment method:

Credit Cards:

 Name on Card:
Card Number:
 Exp. Date:

Please enter the 3-digit value at the end of the number printed on the back of your card.

Billing Address 1 on card: (must match)

Billing Address 2 on card:

City:

State/Province:

Postal Code:

Country:

1)My estimated monthly usage to be

   Debit my account for this full amount nowOr debit my account at the end of the month

2) Separate billing for each DID

3) Please check which language you wish to use:

EnglishSpanishFrenchGermanItalianPortugueseArabicJapaneseKorean

Automatic debit authorization: The undersigned authorizes Highway Telecommunications USA to debit the above credit card in payment for services performed in connection with long distance calls generated by the user so designated in this agreement. The undersigned also agrees to a charge of 3.5% credit card processing fee if paying by credit card (based on the monthly usage). A fee of $4 a month will be applied if usage on a given month is less than USD$20.00. Highway Telecom reserves the right to refuse service.

Signature:
 Date:

Please list the complete phone numbers that you would like to use the service from:

Include country code, area code and phone number.

1:

2:

3:

4:

5:

6:

Please fill out, print, sign and fax this form to our office at 1-305-935-3250.Your order will be processed within one working day and access numbers will be e-mailed to you. Thanks for your business!