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Signup Form for Long Distance Service

  • Please provide the information requested below. Use the tab key to move between fields.
  • When you have completed the application, click on the submit button.
  • A telecommunications professional will contact you to provide a free personal consultation to review your specific needs, questions, and concerns, and to complete your application.

Thank you for using The Long Distance Shop to shop for your telecommunication needs.
We value your business, and promise to work hard to keep it.

Contact Information:
Name    Phone
 Email   Fax

Billing Name (exactly as it appears on your local telephone bill)
Local Telephone Company

Billing Address:
Address1
Address2
City  State  Zip
Physical Address: (if different)
Address1
Address2
City  State  Zip

SSN/FED ID#               
 Current LD Carrier    Monthly Usage      

 Business Type

Credit References for Business Customer:
Bank Name Address  Phone Number   Account Number
Company Name Address  Phone Number  Account Number

 

Services Requested

Residential

 Business

 800 Service		 IntraLATA Service  Also known as Local or Regional Long Distance.  These calls may now be carried by either your local or long distance carrier. 

Main Billing Phone Number (primary phone number that appears on the top of your local telephone bill)

Additional Phone Numbers
  
 

IIf you require additional space for telephone numbers you have several options. You can email them to us, fax them to us at: 800-416-5930, or provide them to the telecom professional who contacts you to verify and process your order.

Toll Free Services

I want to switch my existing 8xx number(s).
8xx Number Ring To Number
  I want a new 8xx number.     Quantity requested
Have my new 8xx Number(s) Ring To:
    
    
    
    
    

IIf you require additional space for toll free information you have several options. You can email them to us, fax them to us at: 800-416-5930, or provide them to the telecom professional who contacts you to verify and process your order.

Allow toll free service from the following locations:
Alaska     Hawaii     Canada     Guam     PR/USVI

Calling Card Information

 Quantity requested     Allow International service

Names to appear on cards
   
   

Additional Services Requested

Account/Security Codes

Billing Options    

Notes (enter comments/questions/special needs here)