CUSTOMER ACCOUNT INFORMATION BILLING INFORMATION

Company Name:	Company Name(If Different):
Contact Name:	Billing Contact:
Physical Address: _____________________________ _____________________________ _____________________________ _____________________________	Billing Address: ________________________ ________________________ ________________________ ________________________
Telephone Number:	Telephone Number:
Fax Number:	Fax Number:
Email Address:	Email Address:

Type of Business: Proprietorship Partnership Corporation	Tax / DL Information: SS # __________________________ DL#_________________DL/ST____ FED ID# ______________________	Years In Business: Years: ______________ Months: _____________
Principals / Corporate Officer’s Names 1. _______________________________ 2. _______________________________ 3. _______________________________	Title: 1. _________________________ 2. _________________________ 3. _________________________	Telephone Number: 1. ________________ 2. ________________ 3. ________________
Bank References: 1. _______________________________ 2. _______________________________ 3. _______________________________	Contact Name: 1. _________________________ 2. _________________________ 3. _________________________	Telephone Number: 1. ________________ 2. ________________ 3. ________________
Trade References: 1. _______________________________ 2. _______________________________ 3. _______________________________	Contact Name: 1. _________________________ 2. _________________________ 3. _________________________	Telephone Number: 1. ________________ 2. ________________ 3. ________________

Term of Contract: Contract Length: __________________	Contract Start Date:	Contract Ending Date:
Total No. Units _______________ Talk GRP 1: ($ 18.00 per mo.)	Total No. Units ______________ Talk GRP 2: ($ 5.00 per mo.)	Total No. Units ___________ Talk GRP 3: ($ 5.00 per mo.)
Talk GRP 1 Total $ ____________	Talk GRP 1 Total $ ____________	Talk GRP 1 Total $ ___________
Billing Cycle: Monthly Quarterly Annually	TOTAL MONTHLY BILLING $ ________________	Customer Initials: _______________

Special Instructions: __________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________