ORDER FORM FOR GLOBALTEL ACCOUNT

Customer #

 *

Please Print and write All Information 

Agent #

 705-Shishido

  　GLOBALTEL "Providing Low US Rates To The World"       Print out and   Fax to: (81) 03-5244-2445

  • NAME (Person, Company or Organization): _________________________________________
  • Contact Person: ______________________________
  • Tel: [    ] (         ) ____________________________ Fax: [      ] (          ) _____________________________
  • Address:__________________________________________________________________________
  • City ____________＿＿__ State＿＿＿＿＿＿_____Postal Code _________＿___Country_________________
  • Email Address: ___________________@___________________________________
  • Payment Information: ( x ) Credit Card 
  • Cardholder: Name: __________________________________
  • Credit Card type:  (    ) VISA (    ) MASTERCARD    (    )AMERICAN EXPRESS   (     ) DINERS CLUB (     ) JCB
  • Note: All credit card accounts are checked for validity. Please allow 48 to 72 hours for processing new accounts
  • Print Your Credit Card Account Number  Below (after xxxx) Expiration Date
    • 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　

    xxxx

    		 　 　 　 　

    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 COPY OF FRONT OF CREDIT CARD OR COPY OF YOUR RECENT CREDIT CARD BILL.

     Agreed to by (Cardholder Signature Only):

    ____________________________________________________________ Siganture  

    CALLBACK NUMBERS -To register your phone No.

    [Country code] +(City Code) Required

    PIN #

    (Your 4 digit number）
    [     ] (       ) 　
    [     ] (       ) 　
    [     ] (       ) 　

    List all telephone, fax and cellular phone numbers to be connected under CALLBACK NUMBERS. List your [country code] (city code) and local number. GlobalTel will assign all other numbers. The first two lines (access numbers) are free of charge; additional access numbers cost $1.00 per month. ACCOUNT and PIN numbers are used only when you travel to change your callback number, greeting message, extension number, or hotel room number.

    Language Choice for Voice Prompts (Please check one):　

    (    )English   (    )Spanish    (   )Portuguese    (     )French  (    )Japanese 　

    Special Instructions: __________________________________________________________________________________________________________

    　

    Mail to:1-22-6, Yanagihara, Adati-ku, Tokyo, 120-0022, Japan?iTo Alcaeus Corporation Shishido?j

    Fax to:( 81) 03-5244-2445 (Agent in Japan)