“Providing Low US Rates To The World” /

ORDER FORM FOR GLOBALTEL ACCOUNT

Fax to 1-952-487-3461 or 1-888-622-7616 with clear copy of both sides of your credit card and photo ID (passport or driver license).
Or email scanned documents to
Please Print or Type All Information / Agent # / 163 / Customer #
NAME (Person or Company name):
Contact Person: / Tel: [] () / Fax: [] ()
Street Address:
City: / State: / Zip/Postal Code: / Country:
Email Address:
Cardholder’s Name:
Credit Card type:VISA MASTERCARD AMERICAN EXPRESS DINERS CLUB Discover JCB-Japan
Note: All credit card accounts are checked for validity. Please allow 24 hours for processing new accounts.
The credit card authorization will put a hold on the total limit amount requested for 10 days.

Print Your Credit Card Account Number Below Expiration Date

xxxx

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year

I hereby authorize GLOBALTEL of Boca Raton, Florida, USA, to bill my credit card for all charges generated by my account. I agree to this method of payment, and agree that all sales are final, during the period of time that I subscribe to the services provided by GLOBALTEL. I further agree to promptly notify GLOBALTEL if my credit card is canceled or will be unavailable to be charged for any reason. Attach: (1) copy of BOTH SIDES of the signed credit card (or a recent credit card billing statement showing name, billing address and credit card number) (2) copy of PHOTO ID (driver license or passport).

Agreed to by (Cardholder Signature Only): ______.

Services Needed at NO EXTRA CHARGE (Rates may vary):
International Callback and Direct Dial/Calling Card Dial Direct/Calling Card Only
PIN NUMBER (4 DIGITS): Your PIN number is needed to access WEB-E-BILL – Our Online Billing site and also enable you to use your account when you travel

CALLBACK NUMBERS

[Country] (City/Area) Codes Required / Credit Limit
per week/weekend /

CALLBACK NUMBERS

[Country] (City/Area) Codes Required / Credit Limit
per week/weekend
[] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00 / [] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00
[] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00 / [] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00
[] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00 / [] () / $25.00$50.00$75.00$100.00$150.00$200.00$250.00$300.00$350.00$500.00$600.00$700.00$800.00$900.00$1000.00

Under CALLBACK NUMBERS List all telephone, fax and cellular phones to be connected. List your [country code] (city code) and local number; (USA, Canada and Caribbean countries use [1] (AREA CODE) + local number. GlobalTel will assign up to two lines (ACCESS NUMBERS) free of charge; additional access numbers cost $1.00 per month. You must specify weekly credit limit for each callback line and/or calling card. This will enable you to budget the amount you want to spend for this service. We will authorize your credit card for the total “limit” requested above to check the availability of funds. All clients are responsible for any call charges regardless of the limit above.

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Special Instructions:

2600 N. Military Trail, Suite 215, Boca Raton, FL 33431-6309 * Fax: +1-952-487-3461 * Email: