Last Name                                           First Name

Address  

City                                              State or Province        Postal Code        Country  

Phone                                   E-mail

(The above information is also used for billing and for 911 service.)

I would like to purchase:

   Live X Agent Package   $29.95  Per Month
        (Includes 1000 minutes to North America included, additional minutes available at US .03 per minute) 

   Basic Phone Adaptor: $49.95   Connect a regular analog phone to the adaptor in order to use
                                                          (If you already have an ATA type device or VOIP phone you will not need this.)

Billing and Payment

Country Communications will invoice the customer one month in advance for monthly services and the following month for long distance and additional usage based services and has the customer’s approval and authorization to collect payments from the client using the method selected by the client below. 

I would like to provide my credit card information over the phone with a customer service representative.

The representative can call me at this phone number:          OR...

I am providing my Credit Card information as follows:            

Visa      Master Card    

Card Number                                                  Expiry Date
      

Name on Card

 

*The billing address for the credit card must be the same as the customer's address listed at the top of this agreement form.

(Preauthorized banking payments are also possible, please call for information.)

The customer acknowledges that they have read and agree to all of the terms and conditions associated with this agreement. For additional information regarding the terms and conditions and to view the latest copy or changes made to the terms and conditions or proper use of service, please visit our Terms & Conditions page.

By typing my name in the field below, I here-by give my authorization to provide the services selected above and debit my credit card according to the Account Payment instructions selected above.

Name                                                              Today's Date

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you MUST fill in the blank below with
this code >     livex21

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