CUSTOMER INFORMATION
Company Name
Contact Name
Title
E-Mail Address
Address
City
Province	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory in Canada
Postal Code
Contact Telephone
Contact Fax
SERVICES REQUIRED
Telephone Numbers to be transferred to Telecom Options Inc.
	Voice Fax Modem	Do not enter any spaces or parentheses or hyphens. Please indicate what the line is used for. Choose from the drop down menu. If you have more than 5 numbers to transfer, please complete another application form or e-mail a list of your telephone numbers at infotel@telecomoptions.com.
	Voice Fax Modem
	Voice Fax Modem
	Voice Fax Modem
	Voice Fax Modem
Toll-Free Numbers to be transferred to Telecom Options Inc.
		Please indicate the terminating number where the toll-free number should ring in the second box.
Calling Cards to be provided by Telecom Options Inc.
Canada/U.S. Cards		Please indicate the number of each type of card required.
International Cards
BILLING INFORMATION
Billing Medium	E-Mail Hard Copy by Mail
Account Codes	None Non-verified Verified
By submitting this application, I authorize Telecom Options Inc. to select the carrier of their choice as our long distance provider. I have full authorization to register the above telephone numbers and assume full responsibility for all calls associated with those telephone numbers.
Thank you for choosing Telecom Options Inc.

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