Order/Activate English Date of Order JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 Name * Address * City, State Zip * Country * Telephone Number (Country Code) Area Code-Telephone Number * Email address * Shipping same as billing * Yes No Shipping Address Shipping City, State Zip Shipping Country MTA 3328 Router Adapter $149 Yes No MTA 3328-2RE WITH FAX $175 Yes No XJ100 Wifi Telephone $199 Yes No XJ200 Wi-Fi Handheld $225 Yes No Coupon No. For Special Pricing Enter Plan Requested * Prompt in English Yes No Prompt in Spanish Yes No Selected New State and Area Code you would like * Additional Telephone Number(s) $10/Month Yes No Additional Area Code(s) and State(s) Requested Toll Free Number in USA $15/Month Yes No Optional Insurance $3 per month Box -Wifi $10/mth * Yes No VISA Yes No Master Card Yes No American Express Yes No Credit Card Number * Expiration Date (Day Not Required if not on Card) * JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 CSIC (3) Numbers on back of Card Signature Line * I Accept the Terms and Conditions set out by VoiceNetLink * Yes No MAC Address-Located on the Bottom of Adapter

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