Sign Up With Vicom! Please complete, print, sign and fax this form to Vicom.
Title  First Name  Surname(s) 
Tax Number (CIF)  Agent  Referred by Customer # 
Company Name 
Street Address 
City  Province/County 
Postal Code  Country 
Phone    Fax    Email 

The service should be activated on the following telephone lines:
       

Billing Address (only if different)
Company 
Street Address 
City  Province/County 
Postal Code  Country 

Bank Information (Account must be in Spain)
Bank Name 
Bank ("Entidad")    Branch ("Sucursal")    Control ("DC") 
Account Number ("Cuenta")  (10 digits - start with zeros if necessary)
Exact Name of Account Holder 

Credit Card (only charged if bank debit fails)
Exact Name on Credit Card 
Credit Card Number  Expires 

Additional Information
Language   Invoice sent by   Where did you hear of us? 

I authorize Vicom to charge all calls to the above bank account, or failing that, to the above credit card.

Bank account holder's signature _________________________________________________

Credit card holder's signature _________________________________________________


Don't forget to print and sign then fax or mail form!
Vicom, Apartado 205, 07181 Palma Nova, Baleares, Spain
Tel: +(34) 971-677469    Fax: +(34) 971-676822