CONFERENCE CALLING SERVICE REQUEST FORM
	Residential 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


Customer Name:
Contact Name:
Social Security #:
Physical Address:
City:
State:
Zip:
Fill below if different from above:
Billing Address:
Billing City:
Billing State:
Billing Zip:

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

Please list the person's name who will have access to this service in order to host conference calls and to be considered the responsible party by CA Affinity.
Chairperson:
First Name:
Last Name:
Please check number of lines: 8 16
By submitting this form, I agree to be responsible for payment of all charges incurred by the person 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 resaponsibility 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.

Contact Information