Secure Customer Order Form 

Spanish
Portuguese 
Name: (Person, Company or Organization)
Contact Person:
Email:
Telephone:
Fax:
Street Address:
Apartment/Suite Number:
City:
State:
Zip/Postal Code:
Country:
Payment Information: 
Credit Card Cash with Credit Card Guarantee Pre-Paid/Wire Transfer
Cardholder's Name:
Credit Card Type: 
Visa Mastercard American Express Diners Club JCB
NOTE: All credit card accounts are checked for validity. Please allow up to 24 hours for processing new accounts.
Credit Card Number: 
Expiration Date:
I hereby authorize GLOBALTEL USA,  to bill my credit card for all charges generated by my account. I agree to this method of payment, and agree that all sales are final, during the period of time that I subscribe to the services provided by GLOBALTEL.  I further agree to promptly notify GLOBALTEL if my credit card is canceled or will be unavailable to be charged for any reason. (ATTACH COPY OF FRONT OF CREDIT CARD OR RECENT CREDIT CARD BILL).
User's Phone Number 
(Your Callback Number)		 Access Number 
(Assigned by GlobalTel)		 Security Code 
(PIN)
+ (561) 
+ (561) 
+ (561) 
+ (561) 
+ (561) 
+ (561) 

Language choice for voice prompts (please check one): 
English Spanish GermanFrenchPortuguese Japanese 

ItalianArabicMandarin RussianPolish

Special Instructions: 



GlobalTel 
303 Park Avenue South Suite 1028 
New York, New York 10010 
Phone (212) 813-2012 
Fax (212) 813-2085