Change Credit Card Form
CUSTOMER INFORMATION: (Please fill out completely)
CUSTOMER #:_______/_________ Company or Name:____________________________________
(NOT Tracking #) (Exactly as on orignal order)
Contact Name (if company)___________________________________________________________
(Exactly as on original order)
CREDIT CARD INFORMATION: (All information below is required)
CARD TYPE o
American Express o
Diners Club o
MasterCard/EUROCARD o
VISA
Cardholder Name (Exactly as on Card) __________________________________________________
Card Number _____________________________________________ Expires _________________
Credit Card Billing Address ___________________________________________________________
City ___________________________________ Country _______________ Postal Code__________
E-mail ___________________________________________________________________________
AGREEMENT: (Signature is required)
I the undersigned hereby:
Authorize AmeriCom Inc., and its underlying carrier to take all steps necessary to provide
telecommunications services to the undersigned.
Agree to pay all charges related to the telecommunications services in immediately
available U.S. funds to be charged to the above VISA, MasterCard, American Express, or
Diners Club credit card. This authorization shall remain in effect until written notice
is received from the undersigned to cancel this authorization.
This item applies ONLY if FOLLOW ME service was selected: Agree to be responsible for
payment of all applicable charges detailed on my call detail report incurred as a result
of the use of my Follow Me Service, including but not limited to the use or misuse by an
unauthorized third party, or any error, accidental use or loss. AmeriCom and its suppliers
specifically disclaim any liability, loss or risk which is incurred as a consequence,
directly or indirectly, of the use of the Follow Me Service. The undersigned agrees to
indemnify and hold harmless, AmeriCom and its suppliers, from any loss damage or expense
(including reasonable attorney fees) that AmeriCom or its suppliers may suffer as a result
of a breach by the undersigned of the forgoing agreement, or as a result of the collection
efforts that AmeriCom or its suppliers may reasonably incur by reason of any said breach.
Authorized Signature ________________________________________________________________
Printed Name _____________________________________________ Date ____________________
Sales agent #3750
Print, fill out this form and fax it to:
178 4412250 (solo per l'Italia)
+39 0270031994
or +1 2093913580
or, Mail to:
WorldXS.net Telecommunications
c/o Teknosurf.it Srl
Corso Alfieri 250
I-14100 Asti AT, Italy