ACI Long Distance Service Agreement
Please send me an ACI Referral Kit. I want to refer others and receive credits
CUSTOMER INFORMATION - Fields in BLUE are mandatory
Full Name:
E-Mail:
Street Address:
City:
State:
Exactly as it appears on Local Phone Bill
Please Select ALABAMA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT of COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IA KS KY LA MA ME MD MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY PR VI Zip code:
Main Telephone Number
Estimated LD Usage Account Type
Select Acct Type Residential Business Sole Proprietorship
Social Security # or Federal Tax ID
Business Name if not a residential account
LONG DISTANCE SERVICE ORDER - List ALL numbers you wish to switch
Check to add MAIN TELEPHONE NUMBER
Tel Number 1 ==>
No spaces or dashes
Rate Plan
Choose Your Rate $.069 Interstate - 15% referral fee $.059 Interstate - 10% referral fee $.049 Interstate - 5% referral fee In State & State-to-State State-to-State only In State only
Line identifier
(Optional)
This will identify the line responsible for calls on your invoice and can be the telephone number or name (Home line, Fax line, Modem line)
Check to add 2nd TELEPHONE NUMBER
Tel Number 2 ==>
Check to add 3rd TELEPHONE NUMBER
Tel Number 3 ==>
CALLING CARD SERVICE ORDER
Check to add FREE, NO SURCHARGE Calling Card
Number of Cards:
4-digit PIN codes:
1 2 3 4 5 6 7 8 9 10 Qty
Separate multiple PIN codes with commas
TOLL FREE NUMBER ORDER
1 2 3 4 5 6 7 8 9 10 Qty Quantity of NEW Toll-Free Numbers requested
Ring-to Numbers:
The number that will ring when calls are placed to your toll free number
Service Area
United States only United States and Canada United States and Caribbean United States, Caribbean and Canada
EXISTING TOLL-FREE NUMBERS may also be ported over to Alert Communications but require
an additional RESP ORG form which must be executed and faxed to our office. Click here for the form
Optional Credit Card Billing
You may choose to receive your monthly long distance statement directly OR you may choose credit card billing by completing the credit card section below. If you choose to be billed directly leave the credit card section blank.
Credit Card Number::
Name on Credit Card:
Credit Card Type:
Expiration Date:
Visa MasterCard Amex Discover
Select Month January February March April May June July August September October November December Select Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Terms of Authorization - YES! By entering my first and last name in the box below and clicking on the submit button, I agree to the Terms of Authorization listed below for the products and services that I have selected on this order form.
Enter your full name here if you agree with the Terms of Authorization
Terms & Conditions - This order is subject to credit approval and terms and conditions are subject to state and federal laws. Intrastate rates vary by state. Customer hereby agrees to accept financial responsibility for all charges arising from the use of services above. It is my responsibility to notify Powernet Global Communications of any lost or stolen calling cards. The terms and conditions of service are as stated in this business/residential services application and in applicable tariffs. Customer understands that all balances are due upon receipt payable directly to PNG telecommunications, and that all balances outstanding after 30 days are subject to a late charge of 1.5% per month. Letter of Agency - I authorize Powernet Global Communications (PNG) to be my presubscribed carrier for the services and telephone number(s) designated above, and no others. I understand that by signing this form, PNG will become my presubscribed carrier for each service so authorized. I further understand I can only have one primary carrier for each service per telephone number and that I may incur a charge for this change in presubscribed carrier. I represent that I am authorized to designate the presubscribed carrier for the numbers listed above, and I authorize PNG to act as my agent in submitting this authorization designating PNG as my presubscribed carrier for each service above. By signing your name you are stating that all preceding information is correct and that you fully agree to the Terms & Conditions.
Referral information
I was referred by:
Please Select ACI Agent ACI Web Site Referring Customer Affiliate Web Site Not Known
Enter NAME or Customer # if known
==> PLEASE CONTACT ME REGARDING MY INTEREST IN ONE OR MORE OF THE FOLLOWING
Sprint PCS Service - Business and Family plans for every wireless need
Conference Calling
High Speed Data for my home or office
Becoming an Agent for Alert Communications International
© 2003 Alert Marketing, Inc. - All Rights Reserved. The names, logos and taglines identifying products and services are proprietary marks. All other trademarks and service marks are the property of their respective owners.
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