Customer Order Form 

Name: (Person, Company or Organization)
Contact Person:
Email:
Telephone:
Fax:
Street Address:
Apartment/Suite Number:
City:
State:
Zip/Postal Code:
Country:
Payment Information: 
Credit Card Cash with Credit Card Guarantee Pre-Paid/Wire Transfer
Cardholder's Name:
Credit Card Type: 
Visa Mastercard American Express 
NOTE: All credit card accounts are chacked for validity. Please allow 48 to 72 hours for processing new accounts.
Credit Card Number: 
Expiration Date:
I hereby authorize GlobalTel of Boca Raton, Florida, USA, to bill my credit card for all charges generated by my account. I agree to this method of payment during the period of time that I subscribe to the services provided by GlobalTel through its agents, representatives, wholesalers and employees. I agree to notify GlobalTel if my credit card is cancelled or will be unavailable to be charged for any reason. (Send a photocopy of both sides of the credit card.)
Name of Authorized User User's Phone Number 
(Your Callback Number)		 Access Number 
(Assigned by GlobalTel)		 Security Code 
(PIN)
+ (561) 
+ (561) 
+ (561) 
+ (561) 
+ (561) 
+ (561) 

Language choice for voice prompts (please check one): 
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Special Instructions: 

Please Print and  Fax to: [1] (416) 696-7296