Application for Leon Lee Tel/RSLCom
Voice Over Internet Customer #:___________FAX & Tel: (919) 383-6384 Leon Lee Telecommunications Agent#:
18600or send to 1315 Morreene Rd. #24k, Durham NC 27705
(Please TYPE or PRINT)
Residential, Product: _X_
Voice Over Internet (# 970)Contact Name:______________________________
Billing Address:____________________________________________ (No PO BOX, please)
____________________________________________________________
Contact Phone:(_____)_______________ FAX (______) __________________
E-mail:_____________________________________________________
Credit Information
Social Security number: ___________-________-_________________ (required)
Phone number where you will be calling from.
(______)______________________
<= Where you will be calling from. This phone should not be the one that requires dialing an extra "8", or "9" to get an outside line. In this case, it will not work..Charge to your credit card
Payment:
Credit card information: (for those who pay by credit card)
Type of creidt card: Amex Visa Master Discover
Card Number:__________________________________Exp. Date:________
Exact Name on the card:_______________________________
Agreement:
I, the card holder, by signing below authorize Leon Lee Tel. and its carrier to provide me with voice over internet service and charge to my credit card or bill me via local phone bill when service occurs. This authorization remains effective until the account is cancelled.
Signature:_________________________ Date:_________
(required for all applicants)
