GlobalTel Direct Dial 

Order Form

First Name: 
Last Name: 
Company: 
Company/Customer ID,SSN or Passport: 
New Account? 
Yes No
Street Address: 
Apartment/Suite Number: 
City: 
State: 
Zip/Postal Code: 
Country: 
Billing Address(if different): 
Contact Name: 
Email: 
Telephone: 
Fax: 

Credit Card Payment Authorization:  
I do hereby authorize GlobalTel or International Interconnect to debit my credit card for the total amount of my GlobalTel Dial Direct monthly bill. I estimate my monthly usage to total US$ . This authorization is to remain in effect until GlobalTel receives written notification from the undersigned to cancel this authority. 

Type of credit card: 
Visa MasterCard Diners Club American Express 
Credit card number:  
Expiration Date:        
Name of Cardholder's as on credit card:  
Cardholder address: 

Payment by Check: Make deposit check payable to GlobalTel for two months estimated usage and mail to GlobalTel, 2301-47 Thorncliffe Pk. Dr., Toronto, Ontario, M4H 1J5

Service desired: 800 Travel Card Prepaid Calling Card 
Language Preference: 
English Spanish Portuguese Russian 
PIN (Personal Identification Number, 9 to 14 digits provided by GlobalTel): 
Speed Dialing (up to 96 numbers) Yes No if yes, please complete the Speed Dialing Form provided. 

Agreement: By submitting this application, I authorize Globaltel or International Interconnect to charge me on a monthly basis all charges incurred for the telephone services rendered. I further agree to the payment terms listed above. I agree that all sales are final.  

Agent Name:    Agent #: 
Rate #:  
    Please Print and  Fax to: [1] (416) 696-7296