ICS GLOBE

Israeli Communication service

Send Correspondence to: 108 Genessee St, North Bellmore, NY 11710

Customer Service Hours: 9:00AM-6:00PM est. Time

Customer Service Tel. No. 516-679-3674 * Fax No. 516-783-4422

Customer Sign-up application form

Please read Terms of Agreement before you sign-up.

Personal Information

Name

First

M.I.:

Last

Agent / Sub-Agent #:

Address

Street:

Apartment#

City:

State:

Zip:

Daytime Phone Number:

(Area Code and Number)

Fax Number:

(Area Code and Number)

Home Email Address:

Business Information

Name:

Phone Number:

(Area Code and Number)

Address

Street:

City:

State:

Zip:

Email Address:

Payment

Payment method:

Account Number

(without dashes between numbers)

Expiration Date:

Calling Plan/Service:

Initial Charge:

$ (Minimum $50.00)

Please provide an 10-digit PIN # of your choice

The undersigned hereby (I) authorized ICS to take all steps necessary to provide telecommunications services to the undersigned, (ii) agrees to the Terms and conditions stated on the reverse side of this document and (iii) authorizes all charges related to the telecommunications services to be charged to the undersigned credit card (stated in the front page) account (the "Account"). The aforementioned authorizations shall remain in effect until all outstanding charges under the agreement are satisfied or the payment arrangements agreed upon by ICS are in place. ICS shall not be bound by any representation or promise not set forth in this Agreement.

Cardholder Name: (As it appears on Credit Card)

Authorization: yes

* * I have read and understand all the terms and conditions of this application, and my filling in this blank represents my approval and authorization.

Send me a monthly detailed, itemized statement and charge my account $2.00:	yes
Send statement to:	Home
	Business
	Email
Please automatically charge my credit card in the amount of $ when my balance falls below $20.00