Fax to: Mail to: Phone: Sales Agent #: AM2552 Tracking #: (For internal use only)

This is the official service order form. Please print out this form, then complete all information clearly and FAX / or mail it to us. Your service will be established within 2-3 days.

Phone : (702) 638-2398.
FAX : (702) 638-9567.

Mailing Address:

EZTEL International
2402 Parasail Point
North Las Vegas, NV 89031 USA

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Debitalk International callback service order

Customer Information (Billing address must match the credit card billing address)

Company or Name : _______________________________________________

Billing Address : _________________________________________________

City : _____________________________________________

State / Provance : ___________________________________

Zip / Postal Code : ___________

Country : ___________________

Contact Name (if Company) : __________________________________

Phone : _____________________________________

Fax : ________________________________________
(please include country and city codes)

E-mail Address : _______________________________________

CallBack Number Information (numbers you will be calling from)

#	Country Code	Your City Code	CALLBACK NUMBER INFORMATION (Numbers you will be calling FROM)
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2
3
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5
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8

Voice Prompts Language :

oEnglish

Billing Information :

Please indicate;
Recharge amount ($50, $100, $150, $200, $1000) : _______

Payment option (Wire Transfer, US Money Order, Western Union) :___________________

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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.

Signature : ___________________________________________

Printed Name : _________________________________________________

Date : _____________________