Contact Information
Company Name (optional):
First Name:   Last Name:
Date of Birth: - -
(mm-dd-yyyy) 		  Email:
Name of old carrier:   Daytime Contact Number:

Physical Address
Address:
City: State: Zip:

Mailing Address (if different from above)
Address:
City: State: Zip:


Method of Payment

The default method of payment will be by Check or Money Order. You will receive your invoice via mail.

Additional Services Requested

PRIMUS' Calling Card Plan

Yes, I would like a calling card
 No, I wouldn't like a calling card

Telephone Number(s) To Be Registered:

Primary Phone 1 ( )    -  Phone Number 2 ( )    - 
Phone Number 3 ( )    -  Phone Number 4 ( )    - 

Click here if you need more phone lines

  Additional Phone lines

  Phone Number 5 ( )    -  Phone Number 6 ( )    - 
  Phone Number 7 ( )    -  Phone Number 8 ( )    - 
  Phone Number 9 ( )    -  Phone Number 10 ( )    - 
  Phone Number 11 ( )    -  Phone Number 12 ( )    - 
  Phone Number 13 ( )    -  Phone Number 14 ( )    - 
  Phone Number 15 ( )    -  Phone Number 16 ( )    - 
  Phone Number 17 ( )    -  Phone Number 18 ( )    - 
  Phone Number 19 ( )    -  Phone Number 20 ( )    - 

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