PROCOMMDIRECT  SERVICE REQUEST FORM




Address: City: State: 

Postal Code:   Email: 

Phone:   Fax number: 

ANI: YES  NO  If yes, LADA / Phone Number:
I want to use my PIN in the US/Canada  YES  NO

Credit Card Billing Address (if different than Name and Address above)

Name on Card:   CC Address:   City: 

CC State:   CC Postal Code:  Country:

Number of PINs requested:  

Amount of Monthly usage credit per PIN:(30,40,50,100,150,200,300,400,500)  

Type Credit Card: MC,VISA,Amex

Credit Card#:      Exp Mo   Yr  

CCV#: (This is the 3 or 4 digit number on the back of the card after the credit card number)

Charges to Your credit card will appear from ProcommDirect

PROCOMM DIRECT RECURRING CHARGES AGREEMENT

I, the cardholder, by submitting & signing this form below, agree to pay and specifically authorize Procomm Direct, or their assigns, to charge my credit card for long distance services in the amount checked above, per month . I understand that Procomm Direct, or their assigns, have credit card authorization for the monthly credit amount requested, but will only charge for actual services after they have been rendered. Monthly credit amount is an estimate of the charge. I understand that I have 30 days from the date of receipt to dispute any charges and that all disputes must be submitted in writing, via EMail or Fax to PROCOMMDIRECT.NET LLC. I further agree that in the event the above card becomes invalid that I will provide Procomm Direct, or their assigns, with a valid credit card number and pay any outstanding balance owed to Procomm Direct, or their assigns. Further I agree to pay service charges that may result from my bank's denial of valid credit card charges.

All MC / VISA credit card charges will be billed under the name Procomm Direct. I have read and agree with these terms  

Print Name:___________________________________Signature:______________________________________Date:_________

* ProcommDirect *

ProcommDirect Email

Mexico: Tel 01 (228) 816 7170
USA or Canada: Tel 1 888 550-6072

ProcommDirect Email

FAX TO 1 888 550-6072 from US or Canada

When you press the Send this Order button below, this page will Print, Fill in the Amount of credit requested, print your name as it appears on your credit card,
Sign the form and FAX TO 1 888 550-6072 from US or Canada .
Your request will not be processed until we receive your signed authorization.