FSB Telecom - Corporate Service Agreement Form

Online Service Agreement Form

Please complete all sections of the form below. When completed please print and sign before posting to the following address: FSB Telecom, Griffin House, 18-19 Ludgate Hill, Birmingham, B3 IDW or fax to 0808 1800037.

If you have and problems completing the form please call an FSB Telecom advisor free on 0808 1800036.

1. Member Details
Title
First Name
Surname
Mother's maiden name (for security purposes)

2. Contact Details
Daytime Phone Number
Mobile Number
Fax Number
Email Address

3. Company Details
Company Name
Address
City
County
Postcode
Sole trader/ partnership/ Ltd Company
Company registration number
Number of years trading
Billing Address (if different from above)
City
County
Postcode

5. Fixed Line Order Details
Telephone Number	No./lines	BT Post Code

5b. Existing Services (tick all existing BT services)
Featureline	Payphone	Broadband

6. NGN Required
NGN
Terminating Number

7. Broadband Order Type
Type	New Migration
Telephone Number
Mac Code

7b. Broadband Product Type
Broadband 2 Go	Broadband 2	Broadband 2 Share	Professional

8. Mobile Phone Order Details
NC/PM*	Mobile Number	PAC**	Network/Tariff	Monthly L/Rental	Product Description	Product Cost	Total



NC = New Connection, P = Port, M = Migration *PAC = Port Authorisation Code					Total including VAT

9. Instructions to your bank/building society to pay by Direct Debit
Originators Identification Number 948279
To the manager
Bank/Building Society
Address
Postcode
Name(s) of account holder(s)
Branch Sort Code
Bank/Building Society Account Number