VoIP

1
Customer Information Sheet
Primary
Secondary
Date of Birth
Services
VoIP 19.95 per month Freedom Enhanced Plan
Freedom Videophone Plan
Local Phone Service MCI
Trinsic 39.99 (200 Long Distance minutes)
49.00 (unlimited Long Distance) Current
Company _____________________________
Mobile Phones T-Mobile
Sprint Cingular Nextel Current
Company ____________________________
Packet 8

High-speed Internet or Broadband/DSL Zoomlinx
16.95 Broadband/DSL (various)

Satellite TV Direct Dish
Network DirecWay (with Broadband
Internet Access) Current
Company ____________________________
Long Distance 4.95 per month OPEX
Power Net Global Current
Company ____________________________
Two-way Messaging Paging SkyTel Paging
5Linx Representative Name RIN
Health Benefit Savings Card 19.95
84.95 54.95 129.95
Method of Payment Visa
MasterCard American Express
Discover Check Credit Card
________________________________________ Exp
Date ______/______ Security Code
_________ Check Information ______________________
__________________________________________________
_________ Customer Signature _____________________
___________________________ Date
___________________
Rev 4/27/05