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Application Form:

You may download the application form here or fill out the form below.

  Company Name    
 
  Last Name *    
 
  First Name *    
 
  Contact phone *    
 
  Email    
 
  FAX    
 
  Street Address *    
 
  Please send me a bill via:   Mail   Fax   Pickup  
  Phone numbers to subscribe:
 
Area Code   Telephone Number
  *
 
 
 
 
 
  » Billing Information   
 
  Amount    
 
  Please select: Security Deposit 
Pre-paid:
Hold Credit Card for Security Purposes:		  
 
  Name
(As seen on front of the card)		    
 
  Choose Currency
(USD or CAD)		    
 
  Choose Card Type    
 
  Card Number   Security Code:  
 
  Expiry Date      
 

I authorize Base Telecom Inc. To charge above listed credit card for recharging purposes. I understand that all terms and conditions that normally govern the use of a credit card will apply. Security deposit required for Base Corporate rate services. Credit Card will be kept on file for security purposes. Cash value deposit will be held at Base Telecom Inc. until the end of subscribing to the services.