| Location and Billing
Information |
(Name, address
and telephone number MUST be entered exactly as it appears on your
local telephone bill)
* Indicates required field |
| |
| Were you
or are you currently a GeoTel Customer?* |
|
Yes
No |
| Email
Address*:
|
| First
Name*:
|
|
Middle Initial:
|
| Last Name*:
|
| Date of Birth
(mm/dd/yyyy)*:
/
/
|
| Social
Security Number:
|
| Street Address*:
|
| Apt:
|
|
City*:
|
|
State*:
|
| Zip Code*:
|
| Daytime Phone
Number*:
-
|
| |
| Account Information |
| Main Telephone
Number*:
-
|
| Local
Telephone
Company*:
|
| Current Long
Distance Company: |
|
AT&T
|
|
MCI |
|
Sprint
|
|
Other
|
| Enter up to
three telephone numbers
you would like to switch over to GeoTel: |
| Line1:
|
| Line2:
|
| Line3:
|
| I would like
to have
the following number of Calling cards: |
|
0 (I
do not need a calling card) |
|
1 |
|
2 |
| Customer
Approval |
|
(Please read
all
the following information before submitting form)
By submitting
this form, I authorize GeoTel Communication Services, Inc. to
act on my behalf to notify my local telephone company that I am
choosing Geotel as my primary carrier for residential state-to-state,
in-state and international long distance service (and local service
where available) for the telephone number(s) and my local phone
company may apply a small fee for this change. I am authorized
to change the long distance service for the telephone number(s)
above. The undersigned has read, understands, and agrees to be
bound by the terms and conditions set
forth by GeoTel Communication Services, Inc.
|
|
|
