Long Distance - Order Form
Please enter the information exactly as it appears on your phone bill  
( * indicates required item)
Your Full Name *
Address Line 1 *
Address Line 2
Apartment #
City *
State *
Zip *
Social Security Number *
Email Address *
Re-type Email Address *
Main Telephone Number *
Additional Telephone Number 2

Additional Telephone Number 3
Estimated Monthly Usage $ *
       
Toll Free
I would like to add a toll free number Ring to:
Transfer an existing toll free number Existing Toll-Free Number: Ring to:
Billing:

AutoPay Credit Card automatically billed each month - No monthly billing fee - view billing information online
Direct Bill Receive a paper invoice each month ($2.95 Billing Fee if monthly bill is under $15.00)
If you have selected AutoPay (Credit Card Billing), please enter your credit card information below
Credit Card
Card Number Credit Card ID How to find
Expiration    
Check here if your credit card billing address is the same as above. Otherwise complete information below.
Name on Card
Address Line 1 Address Line 2   
City State   Zip
I have read, understood and agree to the Terms of Service and authorize Mils Research Inc. to switch my long distance provider, including interstate, intrastate, international and intralata/local toll calling.

I am at least 18 years of age     *
Current Long Distance Provider *
Local Phone Company                *

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