COForm

ORDER FORM FOR GLOBALTEL ACCOUNT	Customer #	*
Please Print and write All Information	Agent #	268-Yamazaki

GLOBALTEL "Providing Low US Rates To The World"（これをプリントアウトして必ず英文　(ローマ字）でお書き下さい）

·NAME (Person, Company or Organization): _________________________________________

·Contact Person: ______________________________

·Tel: [ ] ( ) ____________________________ Fax: [ ] ( ) _____________________________

·Address:____________________________________________________________________

·City________________ State( 都道府県）___________________

·Postal Code __________________Country___________________

·Email Address: ___________________@___________________________________

·Payment Information: ( x ) Credit Card

·Cardholder: Name: __________________________________

·Credit Card type: ( ) VISA ( ) JCB ( ) MASTERCARD ( )AMERICAN EXPRESS ( ) DINERS

Note: All credit card accounts are checked for validity. Please allow 24 to 48 hours for processing new accounts

Print Your Credit Card Account Number （カード番号） Below (after xxxx) Expiration Date （有効期限）

xxxx

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, and agree that all sales are final, during the period of time that I subscribe to the services provided by GLOBALTEL. I further agree to promptly notify GLOBALTEL if my credit card is canceled or will be unavailable to be charged for any reason

Agreed to by (Cardholder Signature Only):

　____________________________________________________________ Signature (署名)

CALLBACK NUMBERS　(登録される電話番号-国番号から, 日本は 81 市外局番の前の０(ゼロ)を除いて記入　例：03なら [ 81]( 3) xxx-xxxx [Country code] (City Code) Required	クレジットリミット（クレジットカードの利用制限額　US$	電話番号の登録は最初の2回線までは無料ですが3回線以上は1回線につきUS$1.00/月間のサービスチャージが加算されます。クレジットリミットはその金額を越すとサービスを止める金額です。これの残高が無くなるとその月にはサービスが利用出来なくなるので多めに設定される事をお勧めします。ダイレクト・ダイアル・サービスだけでお申し込みの方もご記入下さい。
[ ] ( )	US$
[ ] ( )	US$
[ ] ( )	US$	Rate: R_JAPN7	ダイレクト・ダイアル・サービスだけ?　Yes No.

List all telephone, fax and cellular phone numbers to be connected under CALLBACK NUMBERS. List your [country code] (city code) and local number. GlobalTel will assign all other numbers. The first two lines (access numbers) are free of charge; additional access numbers cost $1.00 per month. ACCOUNT and PIN numbers are used only when you travel to change your callback number, greeting message, extension number, or hotel room number.

Language Choice for Voice Prompts (Please check one):　（音声メッセージの言語）

( )日本語　( )English ( )Spanish ( )Portuguese ( )French ( )Polish ( )Mandarin ( )Arabic ( )Italian

GlobalTel : 5550 Glades Road, Suite 409, Boca Raton, Florida USA 33431

Fax to: Agent in Japan: 020-4665-8769 or ( 072 )-228-1280