On-Line Application / Agreement

  
 

 Responsible Party Contact Information:

*Name:     Title:    *SS# or Company EIN# :
Address:   City:  State:  Zip:
*Phone:    *E-mail:  Fax:

 * Required information

 Billing Information:

*Billing Address:  City: State:   Zip:
*Billing Phone:           Back line:         Fax:
*Invoice E-mail:  
*Company Name:   Specialty:   Office Hours:

* Required information

*List only the individuals allowed to make changes on this account:

Authorized Employees

Position

Pager #

Home Phone

Cell Phone

 

 Additional Services:

Web Management Skill Specific Call Routing
Auto Attendant (Custom) Time Zone Stamp                       Included
Fax Dispatch zone:
Voice Mail Priority Positioning
Phone Dispatch Music On Hold

* These services are optional. Please check those you wish to use. You may add or delete services at anytime. Call for rates. There is no charge for e-mail dispatching or time zone stamping.

 Business References:

Company Name Address Phone Account Number

(if needed)

These must be current businesses which you or your company have an open active account.

  

Check here if you agree with the terms and conditions of the agreement.

 

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PO Box 140081 • Gainesville, Fl 32614-0081 • 1-800-981-NCCL