More Than Just Long Distance Savings.....

CUSTOMER INFORMATION

Company Name:_________________________________Fed.ID#:_______________________

Contact Name:___________________________________S.S.#:_________________________

Street Address: (no p.o. boxes)____________________________________________________

City:___________________________________________St:___________Zip:______________

Mailing Address:_______________________________________________________________

City:__________________________________________St:____________Zip:______________

PLEASE ENROLL THE FOLLOWING SERVICES TO TELECARE

U.S. MAINLAND INTERSTATE RATE: 8 PER MINUTE + 30 SECOND MINIMUM / 6 SECOND INCREMENTS

ONE PLUS:   Main Telephone Number: (______) ______-________

Additional #'s (______) ______-________     (______) ______-________

Additional #'s (______) ______-________     (______) ______-________

Additional #'s (______) ______-________     (______) ______-________

TRAVEL SERVICE: { } Please Send _____ Travel Cards (15 per. min. No Surcharge)

800/888 SERVICE: { } Please assign a Toll Free Number to ring to: (______) ______-________

Toll Free Service is 9 per minute interstate/anytime in the continental U.S.

{ } Please assign my existing Toll Free Number to your service (NEED to contact me)

CELLULAR L.D. : { } Please assign my cellular long distance #: (______) ______-________

cellular long distance is 15.5 7 AM to 7PM and 12 7PM to 7AM in Cont. U.S.

CUSTOMER AUTHORIZATION

I authorize Telecare, Inc. to provide my long distance service as my underlying long distance provider,

and to act as my agent in all matters related to providing my long distance service for the telephone

number(s) listed on this form. I understand that: (1) I may only subscribe to one long distance carrier

for the listed telephone number(s). (2) There may be a one time fee from the local telephone company

for subscribing my long distance service to Telecare. Subscriber, by signing this application,

guarantees Telecare that all statements will be paid on or before the past due date or subscriber will

be responsible for costs associated with collections.

AUTHORIZED SIGNATURE:_________________________________________ Date:______________

(Optional) I authorize Telecare, Inc. to pay my monthly statement by the bank card listed below. I will

receive a monthly call detail report. Credit Card Type: Visa / MasterCard (circle one)

Card#_______________________________________________________   Exp.__________________

Customer Signature:______________________________________________ Date:____________

Agent Number 031/D2D                     BKR# 006/020


YES! Please send me info on:

{ } Telecare/Pagenet Paging   { } Telecare Unlimited Internet Service (17.95 monthly)

For Services Listed Above, Please Print Out This Page, Complete It & Send It To Me...

Or, If You Have Any Questions, write to me:

EARL BRIDGES, 4657 Evans Ave., Saint Louis, MO 63113

 

(12/03)

 

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American Bizopps