SERVICE REQUEST FORM
Conference Call Service Request Form

CA Affinity Conferencing Services
1842 Centre Point Circle, Ste. 128
Naperville, Illinois 60563

Phone: 1-800-707-8688
Fax: 1-800-435-3070
E-mail: acs@affinityselect.com

Billing Information
Name of Business:
Business Type:
Contact Name:
Title:
Billing Address:
Federal Tax ID #:
City:
County:
State:
Zip:

Fill below if different from above:
Physical Address:
City:
State:
Zip:

Contact Information
Main Billing Number:
(eg. 262-593-9032)
Fax Number:
(eg. 262-593-9030)
Email Address:

Please note that if only one access code is desired, list only one chairperson name. More chairpersons can be added at a later time and all chairpersons listed will be considered the responsible party by CA Affinity for this account.

Chairperson 1:

  
First Name:
Last Name:
Ready Conference:     yes   no
If Ready Conference selected,
please check number of lines:   8   16   24   N/A

Chairperson 2:

  
First Name:
Last Name:
Ready Conference:     yes   no
If Ready Conference selected,
please check number of lines:   8   16   24   N/A

Chairperson 3:

  
First Name:
Last Name:
Ready Conference:     yes   no
If Ready Conference selected,
please check number of lines:   8   16   24   N/A
By submitting this form, I agree to be jointly and individually responsible for payment of all charges incurred by the company listed above, each month, for audio conference calling services provided by CA Affinity Conferencing Services. I understand that CA Affinity provides different levels of conference call services and that it is ultimately my responsibility to know the rates associated with the various types of conference calling made available by CA Affinity including special feature charges. I understand this transaction is conditional upon credit approval. I give authorization to CA Affinity Conferencing Services to review information reasonably necessary to evaluate credit, including credit bureaus.

  

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