First Name:_____________________ Middle Name:________ Last Name:___________________

Street Address:___________________________________________________________________

City ______________________ State _________ Zip/Postal Code____________Country__________

Tel: [          ] (            ) __________________________ Fax: [          ] (             ) _____________________

Email Address: _____________________@ ________________________

Cardholder's Name: _________________________________________________________

Credit Card type:  [ ] VISA      [ ] MASTERCARD     [ ] AMERICAN EXPRESS       [ ] DINERS CLUB      
Note: All credit card accounts are checked for validity. Please allow 24 hours for processing new accounts. The credit card authorization will put a hold on the total limit amount requested for 10 days.

Print Your Credit Card Account Number Below:																	Expiration Date:
																xx xx
1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16		Month		Year

I hereby authorize GLOBALTEL of Boca Raton, Florida, USA, to bill my credit card for all charges generated by my account. I agree to this method of payment, and agree that all sales are final, during the period of time that I subscribe to the services provided by GLOBALTEL. I further agree to promptly notify GLOBALTEL if my credit card is canceled or will be unavailable to be charged for any reason. Attach: 1) copy of BOTH SIDES OF CREDIT CARD (or a recent credit card billing statement showing name, address and credit card number); 2) copy of PHOTO ID (driver license or passport).

Agreed to by (Cardholder Signature Only): _____________________________________________.

Services Needed at NO EXTRA CHARGE (Rates may vary): [    ] International Callback and Calling Card     [    ] Dial Direct/Calling Card Only
4 DIGITS PIN NUMBER (for web-bill access and travel function):
CALLBACK NUMBERS [Country code] (City Code) Required	Credit Limit ($)	CALLBACK NUMBERS [Country code] (City Code) Required	Credit Limit ($)
[           ] (             )		[           ] (             )
[           ] (             )		[           ] (             )
[           ] (             )		[           ] (             )

Under CALLBACK NUMBERS List all telephone, fax and cellular phones to be connected. List your [country code] (city code) and local number; (USA, Canada and Caribbean countries use [1] (AREA CODE) + local number. GlobalTel will assign up to two lines (ACCESS NUMBERS) free of charge; additional access numbers/calling cards cost $1.00 per month. You must specify weekly credit limit for each callback line and/or calling card. This will enable you to budget the amount you want to spend for this service. We will authorize your credit card for the total “limit” requested above to check the availability of funds. All clients are responsible for any call charges regardless of the limit above.

Language Choice for Voice Prompts (Please check one): [ ] English   [ ] French    [ ] Spanish   [ ] Portuguese
[ ] Russian   [ ] Japanese   [ ] Polish   [ ] Mandarin    [ ] German   [ ] Arabic   [ ] Italian

Special Instructions: ________________________________________________________________________

________________________________________________________________________________________
2600 N. Military Trail, Suite 215, Boca Raton, FL 33431-6309 * Fax: 1-309-296-9588 *  support@gbtel.com