Uni-Tel Communications Toll Free Only

Service Confirmation Form

Legal Company Name:  ___________________________________________________

Company D.B.A. (Doing Business As):  ______________________________________

Requested Toll-Free Number(s): 

1^st Choice  (_______) ___________ - _____________

2^nd Choice (_______) ___________ - _____________

3^rd Choice  (_______) ___________ - _____________

Ring to Number: (_______) ___________ - _____________

Agent Name: Cognigen   Agent ID: discounted

Customer Information

Billing Name                                                                Contact Phone Number

Address

City                                                                  State                                        Zip

Interstate Rate:  __________ Cents Per Minute                    Product Code: ___________

Intrastate Rate:  __________ Cents Per Minute                                                       

Authorizations:  I authorize Uni-Tel Communication Group, Inc., DBA Global Uni-Tel located at 47 E. Chicago Avenue, Naperville, Illinois, 60540, to act on our behalf in procuring the toll-free phone lines requested herein at the rates provided above with any telephone carrier necessary to implement this order.  Customer shall be billed on a monthly basis, and pay the invoice by the due date stated.  If invoice is not paid by due date, customer agrees to pay $5.00 or the maximum lawful rate under applicable State Law.  Customer shall pay the invoice by the date due stated on said invoice.  This authorization shall remain in effect until further written notice.  Uni-Tel reserves the right to designate or assign this Service Agreement to any subsequent providers or to any other carriers providing service and changing underlying carriers.  Read, understood, and authorized by:

Authorized Signature – Title                                          Social Security Number

Printed Name                                                                                      Date