To use where? (Phones may be returned from other destinations)

Destinations:_____________________________ Start/Return dates: ____________to___________

Credit Card (type):     IMPAC        Amex          Visa           MC          Discover       Purchase Order
 
Name on Card:___________________________________________

Account # or Purchase Order #___________________________________ Expires:______________

Billing Phone # + Country Code:_______________________________________________________

Credit Card Billing Address:_______________________________________

________________________________________________________________________________

Ship to (if different from above or if to Hotel or Business):  

Name (if not to billing person):_________________________  Phone:__________________________

Company/Hotel:______________________________________ Floor/Suite:______________________

Street Address:  ______________________________________________________________________

City/State/Zip:________________________________________________________________________

Transaction: By signing  below, client authorizes InTouch USA to process credit card vouchers in client's name and pay all charges incurred under the terms and conditions of this agreement.  Airtime use is  determined by reading  phone meter and verifying against carrier invoice.

__________________________________________________________  _____________________________
Card holder's signature                                                                Date                      Initial for theft protection $2 per day 
                                                                                                                                                        covers 1/2 replacement cost.

FAX application, copy of credit card (front and back), & drivers license or passport to 1-703-222-9597.
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