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Personal and Business Application Form
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EuroComm Application for Service Form
Name Address
 
Post Code Country
Tel No Fax No
Mobile No E-MAIL
Authorized users   Please enter below the number where you wish to receive a call back

Name Telephone number Name Telephone number
       
       
This part is private, for security reasons only

How long have you lived at the above address?       years Date of birth              
Passport number  Nationality  Forces number 
Mothers maiden name  Where did you hear about our service? 
Where will you mostly be making your calls? 

From:           To:          
Expected usage 

Expected monthly usage (approx.) GB£/US$
Declaration

I hereby apply to become a subscriber to the EuroComm Ltd. international service and agree to the terms and conditions as set out on this website. I understand that l will be responsible for the charges for all the EuroComm Ltd. direct dials, SIM or access numbers issued under this account. I accept that as access to my EuroComm Ltd. international service can be made only from my telephone number(s) or by inserting the account number(s) and PIN(s) known solely to me, I accept full responsibility for the payment of all charges for calls using such number(s) and PIN(s) regardless of whether or not such access was authorised by me.
I hereby authorise EuroComm Ltd. to debit all calls using the direct dial, SIM or international call back service on the telephone numbers listed above at the end of each month, to my credit or cash card as designated on this application (if my expected usage is over £200 per month then on a prepaid basis with an automatic top up equal to my monthly expected usage). If my credit or cash card is lost, stolen, cancelled or expires, for any reason, or if l wish to terminate this authorisation to bill my credit or cash card for any reason, I will immediately notify EuroComm Ltd. and the credit or cash card company.

Signature Date Full Name
Payment methods
CREDIT CARD   (note we cannot accept payment by electron cards.)
Visa / Mastercard / Amex / Delta / Solo / Maestro / Switch (issue no. ...)        (please circle)
Print name (as on card) Card Number 
Start date  Expiry date  Issue no.  Issuing bank 
Your home billing address 
  Post code  Country