6221
[CAPROCK COMMUNICATIONS LOGO]
ACCT..# [ ][ ][ ][ ][ ][ ][ ]
TAX I.D..# [ ][ ][ ][ ][ ][ ][ ][ ]
CHECK ONE Tax Exempt: [ ] (Exemption Certificate [ ] Sole Proprietorship (Commercial)* must be Attached) [ ] Partnership (Commercial)* [ ] Corporation (Commercial)*
COMMERCIAL APPLICATION
---------------------------------------
In Business Since Type of Business
Legal _______________________________________
Name ______________________________________________________________________ Name of Owner/Partner/President
Physical BUSINESS TRADE SUPPLIERS Address ______________________________________________________________________
Suite City State Zip Trade Supplier Name #1 Billing _______________________________________ Address ______________________________________________________________________ Contact Name/Title
_______________________________________
______________________________________________________________________ Street Address Suite #
_______________________________________
Contact City State Zip
Phone (_____) ______________________________________________________________ _______________________________________
Phone #
AP Contact _______________________________________ Phone #2 (_____) ______________________________________________________________ Account #
_______________________________________ - -------------------------------------------------------------------------------- Trade Supplier Name #2
EQUAL ACCESS INSTRUCTIONS INTERNATIONAL ACCESS INSTRUCTIONS _______________________________________
Contact Name/Title [ ] PIC Required [ ] VERIFIED International Access [ ] Y [ ] N _______________________________________ [ ] w/Acct. Codes [ ] NONVERIFIED International Product Number _______ Street Address Suite # # of Digits [ ] Canada Product Number _______ _______________________________________ [ ] 10795 Access ONLY Mexico Product Number _______ City State Zip [ ] Additional #'s listed (See Attached) _______________________________________ - -------------------------------------------------------------------------------- Phone # Type _______________________________________ F=Fax __ (______)-[ ][ ][ ]-[ ][ ][ ][ ] __(______)-[ ][ ][ ]-[ ][ ][ ][ ] Account # M=Modem __ (______)-[ ][ ][ ]-[ ][ ][ ][ ] __(______)-[ ][ ][ ]-[ ][ ][ ][ ] C=Cellular __ (______)-[ ][ ][ ]-[ ][ ][ ][ ] __(______)-[ ][ ][ ]-[ ][ ][ ][ ] BANK REFERENCE
__ (______)-[ ][ ][ ]-[ ][ ][ ][ ] __(______)-[ ][ ][ ]-[ ][ ][ ][ ]
__ (______)-[ ][ ][ ]-[ ][ ][ ][ ] __(______)-[ ][ ][ ]-[ ][ ][ ][ ] Primary Bank Name - -------------------------------------------------------------------------------- _______________________________________
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