General Information

First Name       Last Name   

Company Name, if any  

Mailing Address  

City         State          Postal Code   

E-mail Address  (VERY IMPORTANT)   

Phone Number     Fax Number  

REQUIRED ---         Social Security Number  OR Tax ID  (no dashes please)     

Billing Address only if different from above

Mailing Address  

City         State          Postal Code    

---------------------- Service Information  

Estimated Monthly Usage in US$

1)  New Toll Free Number                                     
                                Number the toll free number rings to:  

2)  Optional Second New Toll Free Number         
                                Number the toll free number rings to:  

3)  Existing Toll Free Number to be TRANSFERRED to PNG     
                                 Existing Number     
                                 Number the toll free number rings to:       
                                                                                                
Note: transferred numbers require a special form that can be downloaded by clicking either option below --

      for the transfer form in Word format, click HERE
      for the transfer form in Adobe format, click HERE

You can also complete ALL INFORMATION ON ONE PAGE AND FAX !!  click HERE for that form!

      Simply clicking will offer the form on your PC. You can complete, print, sign and fax to us.
      OR you can right mouse button on the link above and choose "save target as" to download.

• Please complete and fax this form toll free to 877-728-4647
• If you need more toll free numbers transferred than fit in the form, simply add a page listing the extra numbers

Comments

Payment Information


Card Number      Exp. Month   January February March April May June July August September October November December      Exp. Year (use 4 digits) 

Cardholder Name

Credit Card Billing Address,  if different from address listed above.

AUTHORIZATION FOR CREDIT CHECK -- TERMS AND CONDITIONS

• THIS ORDER IS SUBJECT TO CREDIT APPROVAL. THERE IS A 
  MONTHLY FEE OF $2.50 FOR SERVICE IF YOUR BILL IS UNDER $15 MONTHLY

• 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.

• 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 PRESCRIBED 
CARRIER FOR ONLY THE TOLL FREE SERVICES AND TELEPHONE NUMBER(S) 
DESIGNATED ABOVE AND NO OTHERS.  I UNDERSTAND THAT BY ELECTRONICALLY 
SIGNING THIS FORM, PNG WILL BECOME MY PRESCRIBED TOLL FREE CARRIER FOR 
EACH SERVICE SO AUTHORIZED. I FURTHER UNDERSTAND THAT I CAN ONLY HAVE 
ONE PRIMARY CARRIER FOR EACH SERVICE PER TELEPHONE NUMBER.  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 TOLL FREE SERVICE ABOVE.

By typing your name in the "Electronic Signature" below and pressing the
"PLEASE SEND ORDER" button below, you hereby agree to the Terms and Conditions above and hereby authorize all expenses associated with this account. Additionally,
any charges are authorized to be billed, when due, to this account.

PLEASE CHECK CAREFULLY ALL INFORMATION BEFORE SENDING, THEN CLICK SUBMIT BELOW --