Service Request Form

Long Distance Calling Card
Service Request Form

(All requested information must be provided!)

Your Name (First, MI, Last):
Local Street Address:
Apartment #:
City, State & Zip:
Local Telephone #:
Social Security #:	- -
State Driver's License (State and #):
Date of Birth:
Name of Parent or Guardian:	(This is for credit reference. This should be someone whom we can easily contact and will ALWAYS know how to contact you.)
Parent/Guardian Phone # (incl. area code):
Your Permanent Home Address:	(This should be the address of the parent or guardian listed above.)
City, State & Zip
Your Email Address:

Please read the payment and credit terms in the "Long Distance Agreement" below before submitting this Service Request Form.
By marking "Yes" and submitting this form, you acknowledge that the information you have provided is true and correct and that you are liable for any false or incorrect entry or misrepresentation of the information you have provided.
Once your application is approved, the card will be mailed to the local street address you have indicated.
When you receive your card, you must call the Telephone Center at 379-3000 to activate the card (outside Utah County dial 1-800-370-1106).
Mailing address: PO Box 1009, Provo UT 84603-1009.
Fax: (801) 370-1104

I agree to the terms shown below: Yes No

Long Distance Agreement
I understand that I am responsible for all telephone calls placed using the authorization code assigned to me. Any authorization code assigned to me will only be used by me, and/or in emergencies, by other persons I designate. I am fully responsible for all calls charged on my authorization code. I understand that I am authorized to have only one account and/or one authorization code at any given time. If it is necessary to get a new authorization code I will notify Off Campus Telecommunications and my existing authorization code and/or account will be deactivated. I understand that a new authorization code and/or account will not be opened until any previous account is paid in full. I also understand that for my convenience and protection my account will be given an automatic $100.00 credit limit, without application or qualification. If I exceed the credit limit, my service will be temporarily interrupted until payment is made.

I agree to pay all long distance telephone invoices upon receipt. Payment is considered late 15 days from date of invoice, and my service may be interrupted if payment is not received within 30 days of invoice date. Any balances due at the end of 30 days will be assessed a 1.5% service charge per month on the outstanding balance. In the event payment is not received within 45 days, my account may be turned over to a collection agency. I will be responsible for all costs of collections, reasonable attorney's fees, and up to a 29% collection fee if the account is given to a collection service for collection. A $5.00 reconnect fee, and a deposit of two times the average monthly billing on my account, may be required to reactivate my account if it is deactivated due to late payment. A service fee of up to $40.00 will be charged on all returned checks.

I understand it is my responsibility to notify Off Campus Telecommunications in writing to request that my authorization code be deactivated if I no longer require service. I am responsible for all calls placed on my authorization code until such written notification is given. In the event my authorization code is lost or stolen, I am responsible for all calls billed to my account until Off Campus Telecommunications is notified in writing.

I will notify Off Campus Telecommunications of my forwarding address at least five (5) days prior to moving. I understand It is my responsibility to have my invoices forwarded to my new address.

I understand that any invoice returned to Off Campus Telecommunications by mail will be sent to the permanent address listed above.

I understand that any outstanding balance from my security deposit with an apartment complex on the network may be applied to any outstanding balance with Off Campus Telecommunications upon moving from the apartment complex.

This agreement may be terminated at any time by written notification and payment of all outstanding balances. I understand I am responsible for all calls until such written notification is provided.

OFF CAMPUS TELECOMMUNICATIONS SHALL NOT BE LIABLE FOR ANY GENERAL, SPECIAL, INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGE OF ANY CHARACTER AS A RESULT OF SERVICES PROVIDED BY OFF CAMPUS TELECOMMUNICATIONS OR THE FAILURE OF OFF CAMPUS TELECOMMUNICATIONS TO PROVIDE SUCH SERVICES UNDER THIS AGREEMENT.

Long Distance Calling CardService Request Form

(All requested information must be provided!)

Please read the payment and credit terms in the "Long Distance Agreement" below before submitting this Service Request Form.

Long Distance Calling Card
Service Request Form