Online Service Request
Access.Net callback & 800 TravelCard™ only - for all other services, contact us)
All of your personal information, including your credit card number, is encrypted for secure transmission over the internet. This encryption process converts the characters you enter into bits of code that cannot be read as the information travels over the world wide web.
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| * = Required Fields |
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| Personal Data |
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| Service Request |
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| Type of Service: |
Callback
800 TravelCard™
Both |
| Referred By: |
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| Name of Referral: |
* To leave blank, enter "none." |
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| Client Data |
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| Name / Company: |
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| Contact Person: |
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| Mailing Address: |
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| City, State, Postal Code: |
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| Country: |
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| Telephone: |
* Country Code - City/Area Code - Number |
| Fax: |
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| E-mail: |
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| Payment Information |
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| Cash Prepaid Account |
Check if yes |
| Mexico & U.S. Only |
Cash deposits are accepted at all Bank of America (U.S.) and Banamex (Mexico) branch offices. Checks can be either mailed, or faxed to your Access.Net representative.
If you wish to prepay via cash deposit or check, leave all Credit Card fields blank. We will set up your account, and then contact you with deposit account information, activating your access numbers(s) upon payment receipt. |
| Credit Card Account |
Check if yes |
| Credit Card: |
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| Credit Card Number: |
(please use dashes) |
| Security Code: |
(the three digits following the credit card number, appearing on the rear of your card or on front for AX) |
| Expiration: |
(mm-yy) |
| Card Holder Name: |
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| Card Holder Mailing Address: |
Check if same as above |
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| City, State, Postal Code: |
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| Country: |
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I hereby authorize Access.Net and/or its invoicing entity to charge my credit card each month for all calls billed to my account. |
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| Phone number you can be reached at to verify payment information: |
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| Callback Information |
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| Language Preference: |
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| * Extensions Required? |
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| Estimated Monthly Usage: |
* $ U.S. |
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| Please review your service request information and make any corrections necessary. If complete, click on "Enter Order". |
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