A Service of Premiere Global Services Order Entry Only Date Rcvd_________ Date Entered______ Entered By _______   Channel Bundle Order Form
Scroll down to see pricing. Customer Information
Company or Organization Name		Date
First Name	Last Name
Address
City or Town	State or Province	Zip or Postal Code
Telephone
Administrative User Information
Select an User Name	Email Address Where Faxes Are To Be Sent
Select a Password
Number Selection (Pick One) Get a new toll-free fax number Get a new local fax number (limited availability, call first to check for availability in your calling area) Port (Transfer) this existing telephone number
Bundle Options and Price
Single User $7.95/mo 30 pages per month included, then 9¢ per page Bundle 300 $12.95/mo 300 pages per month included, then 9¢ per page Bundle 500 $15.95/mo 500 pages per month included, then 9¢ per page Bundle 1000 $19.95/mo 1000 pages per month included, then 9¢ per page Bundle 2500 $34.95/mo 2500 pages per month included, then 9¢ per page Setup Fee $10 one-time (An Additional $10 will be charged to Port an existing telephone number.) Outbound faxes to Canada and overseas are at an additional charge. Please inquire for rates.
Billing Information
Visa   MasterCard   American Express
Card Number	Expiration Date	Validation Number*
* The Validation Number is the last three digits printed on the signature strip on the back; or for Amex, the 4 non-embossed digits on the front.
First Name on Card	Last Name on Card
Billing Address of this Credit Card
City or Town	State or Province	Zip or Postal Code
Submit Order
When you click the submit button, the order will be placed and the setup fee will be charged to your card. Within 2 business days you will receive an email with your fax number and an activation link. As soon as you click on the activation link, the fax number will be activated and it will answer and forward all received faxes to the designated email account. You can manage your account at www.fax2mail.com using your fax number and the password you gave above.