Phoenix
Network I
n t e r n a t i o n a l.
Application for Callback Service
To establish a callback account, print this form before you fill it out, then fax it to us at +1-415-243-3955.
Customer
information
Company
Name______________________________________________________________________________________________
Applicant
Name______________________________________________________________________________________________
Billing
Address
______________________________________________________________________________________________
________________________________________________Email
Address___________________________________
Telephone______________________________________
(please
include country and city codes)
___________Please
fax my monthly bill ($5/month)
Account
Information
Monthly
Fees: $5.00 per line. (fee
is waived any month phoning reaches US$50)
Line
1
Primary callback
number_____________________________________________________________________
(Please
include country and city code. Contact
us if you need alternate “rollover” callback numbers.)
Monthly
maximum phoning limit for this line (US$, credit card accounts
only)_______________________________
Please
choose a 7-digit PIN (security code)______________________
Language: (circle one) English / Spanish / Japanese
Line
2
Primary callback
number_____________________________________________________________________
(Please
include country and city code. Contact
us if you need alternate “rollover” callback numbers.)
Monthly
maximum phoning limit for this line (US$, credit card accounts
only)_______________________________
Please
choose a 7-digit PIN (security code)______________________
Language: (circle one) English / Spanish / Japanese
Payment
Information
______Pre-payment by wire transfer or check drawn on US bank.
Prepayment equal to 1 or 2 months’ phoning is recommended ($100
minimum to open account)
Name
of sending bank__________________________________Name of sender or
reference___________________________________
Send
wire transfer payment to:
Citibank,
245 Market St., San Francisco, CA 94104 USA, ABA#321171184,
ACCT#601008717, Swift No. CitiUS33
_____________________________________________________________________________
______Credit card pending Phoenix approval. Total monthly calling limit will be continuously reserved on
card; actual charging is done at the end of each billing period.
$100 minimum authorized monthly limit per line.
No minimum phoning required.
o
Visa o Amex
o
Mastercard o
Diners’ Club
o
JCB
Card
number_______________________________________________________________
Expiry_________________________
Cardholder
name as shown on card (print
clearly)____________________________________________________________
I
authorize Phoenix Network Int’l to charge the amount of my telephone
service each month to my credit card shown here.
I understand that Phoenix Network Int’l will reserve space on
my card every month for my authorized limit, and that this will remain
in effect until I notify Phoenix in writing of any changes or
cancellations.
Cardholder
signature_______________________________________________________________
Date_______________________
Phoenix
agent use only
Rate
Code QPLAN
Agent Code/Subcode YU375
185
Berry Street Suite 1000, San Francisco, CA 94107 USA Tel.
+1-415-243-3200 Fax
+1-415-243-3955 phoenix@qwest.com