Fax to:+1-212-504-80-73
+7-421-279-31-79
Sales Agent #: AM-2327
World Access International Callback   SERVICE ORDER
CUSTOMER INFORMATION (Billing Address must match the credit card billing address)
  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(include extension if required)
 
# CountryCode 
City Code 
Customer Phone Number(include extension if required)
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5
 
 
 
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3
 
 
 
7
 
 
 
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VOICE PROMPTS
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CREDIT CARD   [ ] American Express   [ ] Diners Club   [ ] Discover   [ ] MasterCard/EUROCARD   [ ]VISA

  Card Number ___________________________________________________   Expires _______________
  Name (Exactly as on Card) ________________________________________________________________

AGREEMENT (Signature is required)
    I, the cardholder, by signing below,  agree to pay and specifically authorize the company (or its Designee) to charge the credit card specified above, for long distance telemanagement services.  I understand that my credit card may be charged every week for actual usage incurred.
    I further agree that in the event my credit card becomes invalid, that I will provide the company with a valid credit card number upon request and have charged, or pay, any/all outstanding balances owed to the company.
    I agree that any disputes will not be cause for withholding payment and that I must pay all invoices in full regardless of any disputes being negotiated.  All credits, if any, issued for resolution of disputes will be applied to the current billing cycles invoice in which the dispute is resolved.
      Authorized Signature ________________________________________________________________
      Printed Name ____________________________________________   Date _____________________