Vonage Business Plus	Binary Systems, Inc. is an authorized Vonage reseller
Number Transfer Authorization

This form authorizes Binary Systems, Inc and Vonage to request the transfer of your phone number from your current phone company, and for Vonage to provide your phone services. Please do not make any changes to your current phone number as this may cause a delay or cancellation in transferring your number. This includes adding or removing features, changing services, or requesting cancellation of services. Please complete all fields as appropriate.

Customer Information

Name as it appears on your phone bill Customer Information. Edit to match your name as it appears on your phone bill (if needed).

First Name

Last Name

Note: Business customers should list the name of the person authorized to make changes to your current phone account. The name of your business will be required below.

Enter the address *exactly* as it appears on your phone bill.

Street Number	Street Direction	Street Name	Street Type	Street Suffix
Address2
City	State	Zip Code	Country

Current Phone Company Information (Phone Company you are transferring from)

or, if not listed, enter the name here

Enter the Account Number with your Local Phone Company (Phone Company you are transferring from):

Please check all of the following that apply to your transfer request

I currently have more than one phone number on this account.

Enter the primary phone number on your current phone bill (ex. 732-555-1111)

I am transferring a business phone number.

Business Name:

Enter the Last 4 Digits of your Social Security or Federal Tax Identification Number for verification:

Choose if you want to keep your current phone Directory Assistance listing, or have your number unlisted:
Keep current Directory Assistance Listing (Where Available) Unlisted Number

Phone Number Information

Numbers Being Transferred		Vonage Business Plus Numbers to Replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace
	will be forwarded to and replace

Service Information

PLEASE ENTER YOUR INITIALS IN EACH OF THE BOXES BELOW.

The undersigned designates Vonage to act as my agent for the telecommunications services chosen below. Vonage and Binary Systems, Inc. may act as our communications representative when dealing with equipment and service vendors for all telecommunications services we require (as evidenced by my digital initials).

THE UNDERSIGNED UNDERSTANDS THAT MY DIGITAL INITIALS AFTER THIS PARAGRAPH INDICATE THAT I AM SELECTING VONAGE TO PROVIDE ME, OR MY COMPANY, WITH LOCAL EXCHANGE TELECOMMUNICATIONS SERVICES.

THE UNDERSIGNED UNDERSTANDS THAT MY DIGITAL INITIALS IN THIS PARAGRAPH INDICATE THAT I AM SELECTING VONAGE TO PROVIDE ME, OR MY COMPANY, WITH EITHER LOCAL TOLL ,
OR TOLL LONG DISTANCE TELEPHONE SERVICE
OR BOTH.

Telecommunications companies may deal directly with Vonage in the provision of the telecommunications services noted herein, and provide any information necessary to establish and maintain these telecommunications services for my company or residential line.

Requested Services

By checking this box, you are confirming you want to transfer your Local, Long Distance, Local Toll and International services to Vonage on the listed telephone number.

I am authorizing Vonage to become the local service provider for the telephone number(s) provided in this application. I am also authorizing Vonage to become the local toll, long distance and international provider for the telephone number(s) provided in this application. I understand that I may consult with Vonage as to whether a fee will apply to this change. I also understand that Vonage may have different calling areas, rates and charges than my current local service, local toll, long distance provider(s), and I am willing to be billed accordingly. I also authorize Vonage to obtain billing information, customer service records, and other network information required to provide me with Vonage service.

I understand and acknowledge that I may select only one Local Service, InterLATA (long distance) and IntraLATA (local toll) carrier for each telephone number. I certify that I am at least 18 years of age, and that I am authorized to change the service providers for the telephone number(s) specified in this application. I understand that this application is subject to review and approval by Vonage . I agree that I am responsible for all Vonage charges arising out of my use of their service.

The digital signature below will result in new service or a change from your current provider to Vonage , or both, as requested.

Authorized By

Name:

Date (MM-DD-YYYY):

Email Address

Contact Phone Number

Vonage Business Plus Account Number

DO NOT call your phone company to cancel your phone service. Your number needs to be active to transfer.

By clicking the Submit button, you are agreeing to the above terms and conditions.