Fax to:+1-212-504-80-73
+7-421-279-31-79
Sales Agent #: 2327
ClearWorld International Callback   SERVICE ORDER
CUSTOMER INFORMATION

  Company or Name _______________________________________________________________________

  Billing Address __________________________________________________________________________
  City ________________________________________ Country ________________  Postal Code_________
  Contact Name (if Company)________________________________________________________________
  Phone ____________________________________  Fax _________________________________________
 (please include country and city codes)
  E-mail Address __________________________________________________________________________

CALLBACK NUMBER INFORMATION (Numbers you will be calling FROM)
 
# CountryCode
City Code 
Customer Phone Number
 
# CountryCode
City Code 
Customer Phone Number
1
 
 
 
5
 
 
 
2
 
 
 
6
 
 
 
3
 
 
 
7
 
 
 
4
 
 
 
8
 
 
 
 
  FOLLOW ME: (optional)    [ ]   Enter 5 Digit PIN Code:  ___ ___ ___ ___ ___
CREDIT CARD INFORMATION
  CREDIT CARD:   VISA  MasterCard/EUROCARD  American Express  Diners Club
  Card Number ___________________________________________________   Expires _______________
  Name (Exactly as on Card) ________________________________________________________________

AGREEMENT
I the undersigned hereby:
1) Authorize AmeriCom Inc., and its underlying carrier to take all steps necessary to provide telecommunications services to the undersigned.
2) Agree to pay all charges related to the telecommunications services in immediately available U.S. funds to be charged to the above VISA, MasterCard, American Express, or Diners Club credit card.  This authorization shall remain in effect until written notice is received from the undersigned to cancel this authorization.
3) This item applies ONLY if  FOLLOW ME service is selected above: Agree to be responsible for payment of all applicable charges detailed on my call detail report incurred as a result of the use of my Follow Me Service, including but not limited to the use or misuse by an unauthorized third party, or any error, accidental use or loss.  AmeriCom and its suppliers specifically disclaim any liability, loss or risk which is incurred as a consequence, directly or indirectly, of the use of the Follow Me Service.  The undersigned agrees to indemnify  and hold harmless, AmeriCom and its suppliers, from any loss damage or expense (including reasonable attorney fees) that AmeriCom or its suppliers may suffer as a result of a breach by the undersigned of the forgoing agreement, or as a result of the collection efforts that AmeriCom or its suppliers may reasonably incur by reason of any said breach.
       Authorized Signature ________________________________________________________________
      Printed Name ____________________________________________   Date _____________________