Global Access (tm)    [ WORLD-WIDE BBS DIALING NETWORK ]    Global Access (tm)


                           APPLICATION / AGREEMENT

Account Information (Please Print Or Type)

NAME:
     

ADDRESS:
        

CITY:                                   STATE:          ZIP:
                 

Mailing Address (If Different From Above)

ADDRESS:
        

CITY:                                   STATE:          ZIP:
                 

DAYTIME PHONE NUMBER:
                     

EVENING PHONE NUMBER:
                     

SOCIAL SECURITY NUMBER:
                       

Billing Method (Please Check One)

Ŀ
   CHECK FREE - Send Us A Voided Check And We Will Draft Your Account.

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   VISA      MASTERCARD      DISCOVER      AMERICAN EXPRESS
                                  

ACCOUNT NUMBER:                                     EXP. DATE:
                          

I have read the Terms and Conditions enclosed with this application,
understand all the rates for the service, and agree to allow
G-A Technologies / Global Access(tm) to charge the above payment method
choice for use of the Global Access(tm) service at the rates enclosed.

AUTHORIZED SIGNATURE:                                      DATE:
                           

$ 20.00 One Time Sign-Up Fee
                                   Mail To:
                           Ŀ
                                Global Access     
                            Post Office Box 31474 
                             Charlotte, NC 28231  
                           
