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Text File  |  1993-09-01  |  2KB  |  66 lines
  1.                << HIT THE 'P' KEY TO PRINT >>
  2.                 BUSINESS SERVICE REQUEST FORM
  3.  
  4.     A.F.I. LONG DISTANCE SERVICE - SERVICE REQUEST AGREEMENT
  5.  
  6.  
  7. NAME>                            CONTACT>                 TITLE>
  8. STREET ADD>                                          COUNTY>
  9. CITY>                                                 STATE>       ZIP>
  10. BILLING ADDRESS, IF DIFERENT FROM ABOVE>
  11. CONTACT>
  12. PHONE>                                BUSINESS OR PERSONAL?>    
  13. BUSINESS BANK>                BRANCH>               ACCT NO>
  14. TRADE REFERENCE1>                       CONTACT>          PHONE>
  15. TRADE REFERENCE2>                       CONTACT>          PHONE>
  16. PRESENT CARRIER>               EST. MONTLY LONG DISTANCE BILL>
  17. FED. TAX ID>
  18.  
  19. SERVICE INFORMATION:
  20.  
  21. HOW MANY NUMBERS>         LIST BELOW ALL PHONE NUMBERS.  IDENTIFY WHICH LINES
  22. ARE BILLING TELEPHONE NUMBERS (BTN) NOTE:  YOU MAY HAVE MORE THAN ONE BTN.
  23. ALSO SPECIFY LINE TYPE PER CODE:  F= FAX, M= MODEM, V= VOICE.
  24.   AREA CODE   NUMBER           BTN  TYPE
  25. 1.         -                  
  26.   AREA CODE   NUMBER           BTN  TYPE
  27. 2.         -   
  28.   AREA CODE   NUMBER           BTN  TYPE
  29. 3.         -   
  30.   AREA CODE   NUMBER           BTN  TYPE
  31. 4.         -   
  32.   AREA CODE   NUMBER           BTN  TYPE
  33. 5.         -   
  34.   AREA CODE   NUMBER           BTN  TYPE
  35. 6.         -   
  36.   AREA CODE   NUMBER           BTN  TYPE
  37. 7.         -   
  38.   AREA CODE   NUMBER           BTN  TYPE
  39. 8.         -                              
  40.  
  41. I hereby authorize Affinity Fund, Inc. or their authorized representative to
  42. transfer my long distance line carrier.  I understand that my local operating
  43. company may charge a fee to perform the transfer.  I accept responsibility for
  44. all changes associated with the above telephone number.
  45.  
  46.  
  47. _____________________________________________________________________________
  48. AUTHORIZED SIGNATURE                      TITLE               DATE                                              
  49.  
  50. _____________________________________________________________________________
  51. PRINT NAME
  52.  
  53. _____________________________________________________________________________
  54.  
  55. OFFICE USE ONLY
  56. ANI CONSULTANT SIGNATURE
  57. CONSULTANT ID CODE:  747-0180
  58.  
  59.  
  60. SEND COMPLETED REQUEST FORM TO:
  61. OR FAX TO:
  62. (408) 423-0131
  63. LIGHTHOUSE PRODUCTIONS
  64. P.O. BOX 7885
  65. SANTA CRUZ, CA 95060
  66.