Type  of  product(s): Pre-Paid PIN/ Dial Direct/Recharge Dial Direct

Phone number to setup(only for Dial Direct Products): ___________________

Bank Account # ________________________________________                        Business Account ? Yes/No

Bank Telephone number(with area code): ________________________

email:________________________________________________(Email customers get special offers periodically)

* Checks faxed once need not be mailed later on.

Authorization and Cancellation

1. I authorize the payment to be deducted from my account on or after the date indicated below

2. I understand that I may cancel this payment authoriztion only before I receive a prepaid calling card PIN or ANI number

3. I understand that all ANI/PINs are valid for a period of 3 months from the date of purchase, and that there
     is a $10 cncellation charge per ANI/PIN number in the event I choose to cancel my ANI/PIN or my payment
     is returned. I agree to pay all collection costs, including attorney fees.

Signature:___________________________ Name:_______________________________Date:____________________

Please attach a copy of your check here