AccuChat  The Original 3.9˘ (TX, CO, CA) 
Calling Card              & 6.9˘ Toll Free Access
(No Surcharge* - Billed per minute)

Office Use Only
Sales 860

Auth#

ACCOUNT INFORMATION          [   ] Check here if phone and fax number(s) are added below to QuickChat Service

Account Name

Contact Person

Phone # (        )

Fax # (          )

Billing Address

City

State

Zip

CREDIT CARD INFORMATION (Required - Must Complete This Section Accurately For Application To Be Processed In A Timely Manner.  Your credit card will be pre-authorized for the total of estimated usage! You will only be charged the actual monthly usage, a $1 billing fee, and applicable tax at the end of the billing period. No billing fee will be charged if there is no usage during the billing cycle. No bill will be issued. All your account detail is available via website with assigned user ID & password for your review.

Name That Appears On Credit Card

Billing Address For Credit Card

City

State

Zip

VISA [  ]   MASTERCARD [  ]    DISCOVER [  ]   
AMEX [  ]

 Credit Card #

NOTE:PAYMENTS WILL BE PROCESSED BY Linq Telecom, Inc.(LINQ)

Expiration Date:

PAYMENT OPTIONS (Note: All Individual Accounts Must Choose Either A or B)

[  ]  I authorize payment to LINQ every month using the above credit card.  No Monthly statement will be issued. ($1/mo. Fee- $0 if no usage)

CARD HOLDER INFORMATION (Allow 48 business hours for activation of cards.  Allow approximately 2-3 weeks for card delivery)

1.        Calling card utilizes a 14 digit # for completing calls

2.        Each individual card will have a randomly selected 10 digit authorization # printed on the card.

3.        Please choose a unique 4 digit pin # to apply to each individual card and list accordingly below.

4.        This 4 digit pin # will need to be memorized by the card holder since it will not appear on the card itself.

5.        A one-time processing and activation fee of $1.00 per card ordered will be charged to account.

Name To Correspond With each Card:

Estimated Monthly Calling Card Usage

QuickChat Phone # (When calling from this #, you won't have to enter your 11 digit PIN)

4 Digit Pin #:

1.

[  ] $10 [  ] $25 [  ] $50 [  ] $100

(            ) ______-___________

2.

[  ] $10 [  ] $25

(            ) ______-___________

3.

[  ] $10 [  ] $25

(            ) ______-___________

4.

[  ] $10 [  ] $25

(            ) ______-___________

Cardholder agrees to 1) be liable for all charges to the billing card number issued on this account. 2) authorize credit card payment if account is pass due.  3)  pay a late fee if payment is not made by the due date on the unpaid balance at a rate of 1.5% per month.  4)  hold LINQ and its agents harmless from and damages.  Cardholder represents that he/she has the authority to order this service. LINQ assumes no liability for calls not completed due to circumstances beyond its control.  Unless prohibited under law, LINQ makes no warranties expressed or implied, except as stated in this agreement.  Cardholders Credit Card will be debited under LINQ.  Cardholder accepts the terms and conditions imposed by LINQ for the use of its service and agrees that a facsimile signature is binding.  Customer authorizes a one-time activation fee of $1.00 per calling card to be charged to listed credit card.  *FCC mandated payphone owner’s access connect fee (.30˘) could apply to calls originating from a payphone. (Not paid to LINQ & charge is only on 1^st call in sequence of multiple calls).

Signature:

Print Name:

Date: