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Text File  |  1993-09-19  |  2KB  |  67 lines
  1. 800# SERVICE REQUEST FORM
  2. A.F.I. LONG DISTANCE SERVICE - SERVICE REQUEST AGREEMENT
  3.  
  4. _____________________________________________________________________________
  5. NAME>                            CONTACT>                 TITLE>
  6. STREET ADD>                                          COUNTY>
  7. CITY>                                                 STATE>       ZIP>
  8. BILLING ADDRESS, IF DIFERENT FROM ABOVE>
  9.  
  10. CONTACT>
  11. PHONE>                                BUSINESS OR PERSONAL?>    
  12. BUSINESS BANK>                BRANCH>               ACCT NO>
  13.  
  14. TRADE REFERENCE1>                       CONTACT>          PHONE>
  15. TRADE REFERENCE2>                       CONTACT>          PHONE>
  16. PRESENT CARRIER>               EST. MONTLY LONG DISTANCE BILL>
  17. FED. TAX ID>
  18.  
  19. _____________________________________________________________________________
  20. 800 SERVICE INFORMATION:
  21.  
  22. HOW MANY 800 NUMBERS>     MAIN BILLING TELEPHONE NO.>
  23.  
  24.     LIST BELOW ALL 800 PHONE NUMBERS.  
  25.  
  26.   AREA CODE   NUMBER             
  27. 1.   800   -                  
  28.   AREA CODE   NUMBER          
  29. 2.   800   -        
  30.   AREA CODE   NUMBER           
  31. 3.   800   -            
  32.   AREA CODE   NUMBER           
  33. 4.   800   -   
  34.   AREA CODE   NUMBER           
  35.  
  36. DO YOU WANT TO BE LISTED IN DIRECTORY ASSISTANCE?> 
  37. WHAT NUMBER WILL 800 RING IN ON?>
  38. INTERNATIONAL 800?  YES>      NO>
  39. AREA CODES OR STATES TO BE EXCLUDED IF ANY>
  40. CANADIAN 800?       YES>      NO>
  41. LISTING NAME PREFERRED>
  42. ____________________________________________________________________________
  43.                              
  44. I hereby authorize Affinity Fund, Inc. or their authorized representative to
  45. transfer my long distance line carrier.  I understand that my local operating
  46. company may charge a fee to perform the transfer.  I accept responsibility for
  47. all changes associated with the above telephone number.
  48.  
  49.  
  50. _____________________________________________________________________________
  51. AUTHORIZED SIGNATURE                      TITLE               DATE                                              
  52.  
  53. _____________________________________________________________________________
  54. PRINT NAME
  55.  
  56. _____________________________________________________________________________
  57. ANI CONSULTANT SIGNATURE
  58. CONSULTANT ID CODE:  747-0180
  59.  
  60.  
  61. SEND COMPLETED REQUEST FORM TO:
  62. OR FAX TO:
  63. (408) 423-0131
  64. LIGHTHOUSE PRODUCTIONS
  65. P.O. BOX 7885
  66. SANTA CRUZ, CA 95060
  67.