www.pngtelecom.com
Business & Residential Services Application

INSTRUCTIONS: Please fill out the first 4 Boxes of info as completely as possible. Then complete the Hightlighted sections of the Middle area and then complete all the sections below. When all fields are complete submit! You will receive other instructions once complete!

Customer Information (Where the Service is Located)
Name:
Address:
City: State: Zip:
Social Security #
Federal ID # DUNS#
Owner/President Name:

Billing Information (Must Be Completed)
eMail Address:
eBill Password: (10 Characters Max)
Contact Name:
Contact Address:
City: State: Zip:
Contact Phone#

Credit References (For Business Customers Only - You May Include The Cover Sheet From Your Most Recent Long Distance Bill Instead)
Trade Ref: Contact: Phone:
Trade Ref: Contact: Phone:
Credit Card Payment (Optional) PLEASE CHARGE THIS CREDIT CARD FOR MY MONTHLY CHARGES - AN ITEMIZED CALL DETAIL REPORT WILL STILL BE SENT
Credit Card: MC Visa Amex Discover     Name On Card: Signature:
Card Number: Expiration Date: Today's Date:
Services Desired (Check All That Apply) Business Account   Residential Account

PowerOne(1+) Long Distance    3.9¢ 4.25¢     Account Codes? Yes  No Verified? Yes  No  (# of Codes:   # of Digits: )
Power 3000 Long Distance (Residential Customers Only) Phone Number:                Phone Number:
IntraLata Toll Services   This change applies to local in-state Toll-Call Charges Only, not local service        -   Customer Initials 
800#  Existing 800#  New 800#   Existing 800#        Carrier Existing 800#
                  Ring to Number For 800#         Note: Existing 800# will require a separate RESP ORG form
PowerConnect Internet Access (unlimited dial-up access)         Local Access #
        $14.95 per month $12.95 if you also choose Long Distance or Local Access.
Operating System:  Windows 95/98/ME Windows 2000/XP Windows NT Macintosh - Mac OS Version
Username Desired:      Password Desired:
        (20 Character maximum - You will be contacted if unavailable)        (6-8 Alphanumeric Characters)
Calling Cards   # of cards requested      Pin # Pin # Pin #
PowerDial (1-888-30-30-730 - (Access to lower Rates)        Phone Number      Phone Number

PowerConference - Please fill out PowerConference Moderator Sheet
        (12¢ per minute or 10¢ per minute with the 3.9¢ PowerOne Long Distance Service (Must check PowerOne 3.9¢ option to receive 10¢ per minute rate))

Main Billing Telephone Number
Additional Telephone Numbers            
Authorization for Credit Check - Term & Conditions (See Reverse for Additional Terms & Conditions)
                                                  View Full Terms & Conditions at http://www.powernetglobal.com/corporatesite/servagree.php
This order is subject to credit approval. There may be a monthly free for 800# service.
Terms and conditions are subject to State and Federal laws. IntraState rates vary by state.
Customer hereby agrees to accept financial responsibility for all charges of  any lost or stolen Calling Cards.
The terms and conditions of service are as stated in this Business/Residential Services Application and in applicable tariffs.
Customer understands that all balances are due upon receipt payable directly to PNG Telecommunications, and that all balances outstanding after 30 days are subject to a late charge of 1.5% per month.

Letter Of Agency
I authorize PowerNet Global Communications (PNG) to be my presubscribed carrier for the services and telephone numbers(s) designated above, that I can only have one primary carrier for each service per telephone number and that i may incur a charge for this change in presubscribed carrier. I represent that i am authorized to designate the presubscribed carrier for the numbers listed above, and I authorize PNG to act as my agent in submitting this authorization designating PNG as my presubscribed carrier for each service above.
You may confirm that your services have been changed to PNG by calling 1-800-860-9495.

By checking the box your name, you are stating that all preceding information is correct and that you fully agree to the Terms & Conditions.
I Agree and Understand the Terms of Service     Name:     Date:
Third Party Verification #: