Print, complete and fax to 800-382-7329 or mail to: PCMS • 105 Poplar Street • Erie, PA 16507

PROFESSIONAL COMMUNICATIONS MESSAGING SERVICE, INC.
CUSTOMER BILLING INFORMATION

Company Name: ___________________________________________________

Address: _______________________________ City: _____________________

State: ____ Zip: ____________ Phone: ____________________

Fax: ____________________ Name of Contact: ____________________

Name of Billing Contact: ____________________

Type of Business: __________________________________________________

FOR PAYMENT BY CREDIT CARD ONLY

Credit Card No.: ________________________________ Exp. Date: _________

Type of Card: ( ) Visa ( ) Mastercard ( ) American Express ( ) Discover

Name on Card: _______________________________

CVV#: ________ (3 Digit # on Signature panel, For AMEX above card number)

Address to which credit card statement is mailed monthly:

Address: ________________________________________________________

City: ________________________ State: ____ Zip: __________

If paying by credit card, do you want your card charged monthly? _______

FOR PAYMENT BY CHECK ONLY

If business application, Federal ID #: __________________________________

If individual application, Social Security #: ______________________________

Drivers License #: _____________________ State: _____

Reference: _________________________________ Phone: (____) _____________

Reference: _________________________________ Phone: (____) _____________

Reference: _________________________________ Phone: (____) _____________

Previous account with PCMS? __________

Services desired: __________________________________________________

Base Rate and Options: _____________________________________________

Sales Person: __________________________________

The undersigned declares that the above information is correct and complete and authorizes Professional Communications Messaging Service, Inc. (PCMSI), to charge all amounts owed, by the above company or undersigned to PCMSI that exceed 30 days past due from the original invoice, to the above credit card with a 1.5% late fee.

Name (Print or Type) ____________________________________ Date: _______________

Signature: _______________________________________

Comments: ________________________________________________________________

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