1515 N. Federal Highway Suite 204  Boca Raton, FL 33432
CUSTOMER INFORMATION
Company Name:
Company URL(e.g http://www.click121.com):
Primary Contact
First Name:
Last Name:
Company Phone:        
Company Fax:            
Company Street Address:
City:                  
State/Province:
Postal Code:    
Country:          
Contact E-Mail:           
Tax Exempt Number:
Promotion Code, if any?
121 SERVICE
Your click 121 buttons are similar to telephone numbers. You can place the buttons anywhere on your site. However, if you want to receive your calls at different numbers, you will require a license for each unique telephone number.
License

Telephone Number

(Where calls are to terminate)

Description

(This will appear as the header on the call screen)

Does this number

Terminate in a queue?

1
2
3
WEBMASTER/ADMINISTRATOR INFORMATION
First Name:
Last Name: 
Email:        
Webmaster/Administrator Company:
Phone:
Web Hosting Company : 
Phone:
 

Five hundred free minutes are included in your MAD Quick Quote Program. When your user minutes reaches fifty minutes you may opt continue the service and will be billed directly by Click Interconnect at the special rate of $100 per 500 minutes.

I certify that the above information is true and correct, and submitted to Click 121 with the intention that they rely on it in accepting this application. I have read and understand the Click121.com Service Agreement as provided (and updated from time to time) on their Web site, and indicate my submission of the above and my acceptance of Agreement terms by signing and dating this instrument in the space provided below.

 
Signature:
Title:        
Date: