Please Print this
Form, Fill it in, sign, and then Fax to: (419)-574-6215
Or Mail to:
1stFamily.COM, 444 Meder St., Santa Cruz, CA 95060
OR Sign the form with your PAINT
PROGRAM and then EMAIL TO US: customercare@1stfamily.com
Referred BY:
_____________________________ [FULLNAME OR ID#] _
Customer's Name: _____________________________________________________________
Address:
_________________________________________________________________
City: ______________________________________________ State:
_____ Zip: _________
Phone: ( _____ )______________________________________
Email: ____________________________
Choose one of the following:
UNLIMITED Flat
Rate Residential Line 24 Hour x 7
days/ week. (All day, every day.)
_________ check here.
($29.95/mo + $25 setup fee.) $10 First Month Trial
UNLIMITED Long
Distance VOIP (24 hr/day, x 7
days/week.)
_________
check here.
($29.95/mo (+ $30 setup fee.
Unlimited High Speed Dial Up Internet Access _________ check here
($14.95/mo) No Setup Fee.
1st Family of Health
Plan
_________ check here.
($49.95/mo
Individual OR $59.95/mo Covers the Entire Family) + One Time Admin,
Shipping and Handling - $49.95)
Other Plan ___________________________________ (Identify Here) or call 888- 660-0080 for Help
Paying BY:
You may pay by Credit Card, (VISA, MASTERCARD OR DISCOVER ONLY)
OR Your UNITED STATES Bank Account.
Credit Card #: ________________________________________
Exp Date: __________
Name on the Card:
__________________________________________________
OR Bank
Name: ______________________________________
Bank Account
Routing No. ____________________ Account
No. _________________________
By signing my name below, I
attest that I have read all of the foregoing, have read the detailed information
on the website regarding all other policies and do agree to these terms and
conditions and other policies listed on the website AND if I have given you my
bank account or credit card, or debit card, that I am the authorized signer on
this account, that I am over 18 years of age, and that I would like to take
advantage of the security and convenience of Electronic Check Processing. As a
duly authorized check signer on the financial institution account, or credit
card account identified herein, I hereby authorize 1st Family to charge (debit)
or credit this account, or convert all paper checks, facsimile checks and or
checks by telephone that correspond with the financial institution account
identified herein and which are received by 1st Family for payments due from me
or my company into electronic debits or when applicable, apply electronic funds
transfer credits to same. Furthermore, if such check(s) should be returned as
NSF, or credit cards return declined, I authorize 1st Family to collect such
checks) or debts by electronic debit and to subsequently collect a returned item
fee of $25.00 per check by electronic debit from the financial institution
account identified herein. For accounting purposes, all electronic debits will
be reflected in the monthly bank statement that corresponds with the financial
institution account identified herein and all paper checks, after conversion,
become VOID and will not be returned to me or my company by the corresponding
Bank or 1st Family. I understand and authorize all of the above as evidenced by
my signature below.
Signature:____________________________________________
Date:______
Social Security No. ______________________________
(If you intend to refer others)