Please PRINT THIS FORM OUT and complete the following service request form
and return it to:
Masters Enterprises
924 Shoal Dr.
San Mateo, CA 94404
or FAX it to us @: (415)574-3463 in the U.S.A.
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Application for: ___CallBack ___Extension CallBack ___Traveling CallBack ___TeleCard ___Global Access 800 Customer Information: Individual Name ____________________________________________ Company Name _______________________________________________ Address ____________________________________________________ City______________________ Country___________________ Postal Code___________ Telephone # ___________________________ Fax Telephone # ___________________________
(Fill in one of the circles for credit card you want to use) Payment Method: Visa O Mastercard O American Express O Individual or Company Name on Credit Card ____________________________________ Issuing Bank _______________________________________________ Credit Card # ______________________________________________ Expiration Date ____ / ____ _____________________________________________________________________________________ Every month, Telegroup will debit your credit card for the exact amount you owe for the most recent month's usage. Your Approx. Monthly International Bill $ ________________________
Check Language Response Required: English ____ Spanish _____ User Name _____________________________________________ CallBack # For Our Switch to Dial back: ______________________(Include country code) (This is the number our switch dials you back on to give you a dial tone) Country ______ City _______Telegroup does not extend any warranty, express or implied, including, without limitation, any implied warranty or merchantability or fitness for a particular purpose with respect to quality or availability of service or otherwise, and the subscriber accepts the service without warranty and 'as is'. Rates are subject to change without prior written notice. To terminate service, Subscriber must provide written notice to Telegroup at the address above. Subscriber is responsible for paying all applicable taxes and/or government fees. Telegroup may terminate service at any time. I, the card- holder, by signing, agree to pay and specifically authorize Telegroup(or its Designee) to charge my designated credit card for the total charges billed by Telegroup for my most recent months usage. I agree that in the event my credit card becomes invalid, that I will provide the company with a valid credit card number upon request and have charged, or pay, any/all outstanding balances owed to the company. Disputes must be made in writing (return receipt requested) no later than 10 days after receipt of invoice to Telegroup Customer Service at, 211 S. State College Blvd., Suite 425, Anaheim, CA 92806. I agree that any disputes will not be cause for withholding payment and that I must pay all invoices in full regardless of any disputes being negotiated. All credits, if any, issued for resolution of disputes will be applied to the current billing cycles invoice in which the dispute is resolved. By signing below, I agree to the above terms and conditions.
Authorized Signature __________________________________________ (This signature must match the name as shown on the credit card listed above.) Print Full Name _______________________________________________ Date ___________________________ Agent: Masters Enterprises 151-9000 (415)574-3405 (V) (415)574-3463 (F) email: mast-ent@mast-ent.com