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Regional Rental E-Mail Order Form
For Electronic Transmission Only - Hit "Send Order" Button to Submit

Pager Rental Agreement
Please complete both this Order Form and the Rental Agreement.


Personal Information

     Please enter your Name and Address as they appear on your Credit Card Statement:
       First   MI  Last
     Company 
     Address 
        City  State Zip
     Country 

How may we contact you if necessary? (Day Phone Required for Carrier) Day Hours: How did you find us? Night Hours: ("Yahoo", "Excite",etc.) E-Mail


Credit Card Information
To split charges across two cards: Card #1 Card #2 Expiration Date: Exp: Amt:
Your Rental Pager

Pronto FLX

Bravo FLX

Ultra Express FLX

 $

 $

 $



Local Pager Number Choose an Area Code for your Pager's Local phone number: (If you are ordering an 888 or 800 number, please enter "888" or "800" and then select the option in the Optional Services below. The cost is $6.50/month and $5.25/month respectively.)
Service Options

Regional Numeric Pager Rental

1-Year ($18.99/mo)

6-Mos. ($19.50/mo)

 $

 $

Please choose One Region:

 Western Central Northeast Southeast Southern

Second Region - Add $3.00/month. Please choose your Second Region:

 Western Central Northeast Southeast Southern

- Activation: $15.00
- First 200 calls/month FREE, 17¢/call thereafter
(charged to your credit card on file)




OPTIONAL SERVICES
Additional Per Month VoiceMail Service: MiniMail $ PageMail $ PageMail Plus $ - VoiceMail Access Code (allows you to access your messages) Choose a 4-number Access Code (don't start with "0"): Other Services: Personal 888 Number $ Common 800 Number w/PIN $ Custom Greeting (no VoiceMail) $ Numeric Retrieval $ - Custom Greeting and/or Numeric Retrieval Access Code Choose a 4-number Access Code (don't start with "0"):
Totals
Pager Rental/Service Total $ Processing Charge $ Subtotal $ 2nd Day Delivery $ Overnight Delivery $ Total Charges $

Thank You for Your Order!


Comments/Ship-To Address (if different than above - delays may result):


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