Please fill out form completely. Some fields are required. We will contact you within 1 hour.

Refer a client, and when they sign up for our service you will recieve $5 FREE off your VersaPlanet invoice.

( Offer not valid if you are being sold through one of our dealers. Offer valid if signing directly through VersaPlanet office or web site. )

A RED ASTRIX means you are required to make an entry. Thank you.

*.Title:	Select None Mr. Mrs. Miss Dr.
*.Account Name:
*.Birthdate:
*.SS# or Federal ID#:
*.Mothers Maiden Name:
*.Referred by:
*.Mailing Address:
*.Physical Address:
*.City:
*.State:	Non US Address Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*.Zip code:
*.Do you want Online Billing?	Select Yes No
*.Contact Phone Number:
*.Contact Name:
*.Current longdistance carrier:
*.Email:
*.Average Mo. long distance charges:
*.Name of local phone company:
*.List numbers to change:
*.List an existing 1.800 #:
*.Interested in a new 1.800 #:	Select Yes No
*.Interested in a calling card:	Select Yes No
*.List additional numbers to change:
* Read and accept Electronic Letter of Agency
I hereby authorize Versa Planet Inc to act as my agent in all matters relating to Preferred Carrier Charge(s) for the telephone number(s) listed above. I hereby confirm my decision to charge my Preferred Carrier for interstate, interLATA, intrastate and international long distance services from my current telecommunications carriers for such services to VersaPlanet. I understand that by agreeing to this Electronic Letter of Agency I will no longer be served by my current carrier for such service. I also understand that my local telephone company may charge me a fee to switch my carrier for that service to VersaPlanet. I further understand that I may designate only one carrier for each such service for may one telephone number, and therefore I hereby revoke any previous appointments or selections concerning the telephone number(s) listed above. I understand that VersaPlanet will be the carrier setting my rates for each of the above services. VersaPlanet may elect to provide service via resale, in which event another carrier's name may appear on my telephone bill. By agreeing to this Electronic Letter of Agency, I confirm that I have read and agree to the terms of this electronic Letter of Agency. I certify that I am at least 18 years of age and that I have the proper authority to agree to this Electronic Letter of Agency.