eFax Order Form and Info Order Form: eFax Services This order form allows you to get going with your new eFax service as quickly as possible. Depending on the situation, this may be all the information needed, or there may be additional questions. Unique IDTech Minded Agent DetailsThis information is used to track the order so it's attributed to you. Please fill it out completely.Tech Minded Agent ID NumberTech Minded Agent Name First Last Tech Minded Agent CompanyTech Minded Agent Email* Tech Minded Agent Phone*Tech Minded Agent Phone Type Direct Office Main Mobile Client Details for OrderIn order to setup services, we need the below information. Can't complete the form yet, but want to start? No problem -- start the form, and then press "Save and Continue" at the bottom of the page. Client Company Name*Client Contact/Signer Name for Contract* First Last Client Contact TitleClient Address for Contract* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Client Website Client Email for Contract* Client Phone*Client Phone Type* Direct Office Main Mobile What type of organization is this client?What industry or business are they in? Or what is the organization's overall purpose? This information can often reveal interesting choices that are specific to your client's industry or type.If this is a client request, how did you hear about us?Technical Contact DetailsOften, the technical contact for an organization is different from the contact who signs an agreement. Please provide that contact info as well, if available.Is the technical contact for this organization different from the person who signs the agreement? Yes No Don't know Technical Contact for Client First Last Technical Contact TitleTechnical Contact Email Technical Contact PhoneTechnical Contact Phone Type Direct Office Main Mobile Standard Plans — Monthly BillingeFax Plus Billed Monthly QuantitySend and/or Receive up to 150 pages/month. $0.10 per page for pages beyond above (overage). $10 One-Time Setup fee. Standard Monthly Pricing: Normally: $16.95 per user/month. Your price: $14.95 per user/month. Price: $14.95 Quantity eFax Pro Billed Monthly QuantitySend and/or Receive up to 200 pages/month. $0.10 per page for pages beyond above (overage). $10 One-Time Setup fee. Standard Monthly Pricing: Normally: $19.95 per user/month. Your price: $17.95 per user/month. Price: $17.95 Quantity Standard Plans — Yearly BillingYou get 2 months free with Annual Plan, plus additional savings!eFax Plus Billed Yearly QuantitySend and/or Receive up to 150 pages/month. $0.10 per page for pages beyond above (overage). $10 One-Time Setup fee. Standard Annual Pricing: Normally: $169.50 per user/year. Your price: $149.50 per user/year. Price: $149.50 Quantity eFax Pro Billed Yearly QuantitySend and/or Receive up to 200 pages/month. $0.10 per page for pages beyond above (overage). $10 One-Time Setup fee. Standard Annual Pricing: Normally: $199.50 per user/year. Your price: $179.50 per user/year. Price: $179.50 Quantity Corporate PlanseFax Corporate Billed Monthly QuantitySend and/or Receive up to 100 pages/month. $0.15 per page for pages beyond above (overage). Waived! $100 One-Time Setup fee Standard Monthly Pricing: Normally: $34.95 per user/month. Your price: $29.95 per user/month. Price: $29.95 Quantity eFax Corporate Billed Yearly QuantitySend and/or Receive up to 100 pages/month. $0.15 per page for pages beyond above (overage). Waived! $100 One-Time Setup fee Standard Monthly Pricing: Normally: $359.40 per user/year. Your price: $299.50 per user/year. Price: $299.50 Quantity Type of NumberWhat type of phone number would you like for your incoming faxes?Local and toll free numbers, as well as porting, are all included in your price listed above. Local Number Toll Free IPorting Existing Numbers I have more than one user, the answer varies by user. Thanks! We'll be asking you more on this below. You can place the order without all the porting documentation to get things started (and that's usually best).Local Area Codes RequestedPlease list the local area codes that you are interested in. There's widespread choices, but we have to verify availability once you submit.Multiple Number TypesPlease describe what you would like for local vs. toll free numbers.Setup CostOne time setup fee for all eFax Plus/Pro accounts ordered on this form.Setup fees are waived for eFax Corporate account orders. Price: $10.00 Finalize OrderOnce all the information above has been filled in, and you've entered the quantities for each SKU, press the "Order" below. This will cause your order to be sent to Tech Minded's backend provider/eFax for processing.Total to be billed to card provided for your first month.This includes one-time setup fees, if applicable. $0.00 Payment OptionsChoose your payment type*Please provide your payment information. You will be charged for the event registration fee indicated above. If you are using a purchase order, please include PO number in the notes field below. Orders without valid payment details will not be processed, and will not be considered "placeholders" for an order or pricing. Visa MasterCard American Express Discover Purchase Order Credit Card Number (Visa/MC)*Credit Card Number (Amex)*Credit Card Expiration Date (MM/YY)*Name on Card*CVV (Security Code for Card) for Visa/MasterCard/Discover*The three digit code. Typically on the front of the Visa/MasterCard/DiscoverCVV (Security Code for Card) for Amex*The four digit code. Typically on the front of the American Express card.Purchase Order NumberPayment Notes or commentsPorting In Existing NumbersPorting numbers is normally fairly quick, but may be delayed if there are a number of requests at the same time. You can immediately call forward numbers in the interim -- talk to us if you have questions. If you are ready to prepare the porting number documents, see porting instructions page for more details.Do you have numbers to port? Yes No Maybe. Not sure. Are you ready now to upload porting documents? Yes No File Uploads*Please upload any porting documents or additional information here. Keep Excel files as an Excel file. Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, jpg, png, Max. file size: 25 MB, Max. files: 5. Other Important InformationOther Project NotesThis field is hidden when viewing the formINTERNAL USE: Order Form Submission Details
