Form to gather information from a potential customer so Access America can provide a written proposal

Access America Telephone Company

Request for a Written Proposal for Telephone Services

Form Submitted By: (Please enter the name to be used as the contact person for this account)
First Name:	Middle Initial:	Last Name:

Business Name and Address Information: (Please enter the name and address for the business, this should be a physical address)
Business Name:
Street Address (cannot be a P.O. Box):
Street Address, line 2:
City:
State:		(Note: Local Telephone Service is not currently available in VA)
Zip Code:
Contact's Telephone Number:		(Format XXX-XXX-XXXX)
Contact's FAX Number:		(Format XXX-XXX-XXXX)
Contact E-Mail Address:		(yourname@yourinternetprovider.com)
Best Time to Call:		(i.e. mornings, afternoon, Mondays, Fridays, etc.)
Tell Us About Your Business:
Nature of your business: (Please briefly describe what your business does)
Current Long Distance Carrier
Current Local Telephone Co.
1+ Long Distance
	Minutes of Use
	Cost
	Monthly Fee
800 Inbound Calling
	Minutes of Use
	Cost
	Monthly Fee
Calling Cards
	Minutes of Use
	Cost
Local Telephone Service
	Number of Telephone Lines
	Quantity and Type of Lines
	Quantity and Type of Lines
	Quantity and Type of Lines
	Describe your local telephone services (types of lines and features such as hunting, call waiting, call forwarding, voice mail, etc.):

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Access America 673 Emory Valley Road Oak Ridge, Tennessee 37830 865-482-2140		Copyright 1996-2015 Last Updated: March 6, 2015