1. Customer Information
Full Name:    
Address:      
Town/City:   
Postcode:     Telephone: email:
Your 4 digit PIN:    Your Password:  D.O.B. (DD/MM/YY): 


2. Payment
Prepayment of calls: Credit Card:  Debit Card:  Postal Order (encl.):  Cheque (encl.):
Amount:      £15 (min):       £25 (£5 FREE Refer a Friend):     £50 (+5% FREE):
                  £100 (+10% FREE):        £250 (+20% FREE):           Other £ 
Card Type:     Credit/Debit Card No: 
Expiry Date:     Issue Date:  Switch issue no (if applicable):    
Credit Card Security Nos: (last 3 numbers by your signature on the back of the card)      
Cardholders Name (if different from above): 
Billing Address(if different from above): 



3. Quick Pay
This will enable you to top-up your account by phone using our automated call handling system, or on the internet,
24 hours a day, using the Credit/Debit card listed above.

Please register me for Quick Pay:  Yes:     No:


4. Call Line Identity (CLI)
By registering your home/office number(s) Alpha will automatically recognise you when you call the access number and 
conect you to our switch without you having to enter your Account Number and PIN: Please include the full STD code.

Please register me for CLI:  Yes:     No:  (If Yes, please enter up to 3 phone numbers below)

1.  2.  3.   


5. Declaration
I hereby authorise Alpha Telecom (IOM) Ltd to use my Credit/Debit card to charge the above ticked amount as prepayment 
for my Alpha Access account service.

Customer Signature:______________________________________________________________________________________


6. Referring Customer Details
Account Number (of referring Customer):      Sales Code: 4444UK