| VoIP Customer Order Form |
Name (Person, Company or Organization) :
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Contact Person:
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Email:
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Telephone:
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Fax:
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Street Address (Please use your credit card mailing address):
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Apartment/Suite Number:
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City:
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State:
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| Zip/Postal Code: |
Country:
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Payment Information:
Credit Card Pre-Paid/Wire Transfer Pre-Paid/Western Union |
| Cardholder's Name: |
Credit or Debit Card Type:
Visa
Mastercard
American Express
NOTE: All credit card accounts are checked for validity.
Please allow 12 hours for processing new accounts. |
Credit Card Number:
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Expiration Date:
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Credit Card Code CVV:
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I hereby authorize Alliance to bill my credit card for all charges generated by my account. I agree to this method of payment, and agree that all sales are final, during the period of time that I subscribe to the services provided by ALLIANCE COMMUNICATIONS. I further agree to promptly notify ALLIANCE COMMUNICATIONS if my credit card is canceled or will be unavailable to be charged for any reason.
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| VoIP Termination (outgoing calls) Monthly Limit ($): |
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