510 N Street, SW, Suite 32, Washington, DC  20024  202-829-4444  800-328-2165

Bill To: Ship To:




City: ____________________________________
City: ____________________________________

State:_______________Zip Code:_____________
State:_______________Zip Code:_____________

Business Phone:_________________________________ 
Home Phone:__________________________________

Contact Name:___________________________________  
Rental Information Phone Information

Date of Delivery:__________________     Date of Return:__________________   
Model ______________________________________

Serial Number: _______________________________
Billing / Payment Information (Please select card of use):   Optional Insurance Coverage (Please select):

 ____ AMEX      ____ MC      ____ VISA    ____ DINERS CLUB    
 ____ YES      ____ NO   $2.00 per day / $150 Deductable or ____ Included
 * $350 fee for non-insured loss of GSM equipment
Cardholders Name:___________________________________________________________________

Credit Card Number:__________________________________________  Date of Exp._____________  CV#._______ (3 digit code)

Credit Card Billing Address (if different from above):___________________________________________________________

City:__________________________________ State:______________ Zip Code:_________________

Statement of Authorization

I hereby authorize C I Corporation to bill all rental and call charges to my credit card provided on this agreement form.  I agree that a $500 
authorization will be processed on the credit card provided at the time of this request.  C I may require Customer to make a $500 
deposit and reserves  the right to either refund the deposit if Customer has maintained the account in good standing, or apply
 the deposit to any balance owed by Customer to C I Corporation.

I understand that C I C makes no warranty, express or implied, as to call quality or availability of each country’s cellular
network(s).  The quality of the cellular signal, especially inside buildings will vary. C I C is not liable for direct, special
or consequential damages as a result of equipment, or the service provider.              

I understand that I am fully responsible for all costs of damage, loss, or theft of the phone and equipment.
Also, I am fully responsible for all call charges until service on that phone is deactivated by the service provider.

By signing this agreement, I acknowledge that I have read and understood this statement of authorization and authorize ICS

to charge my credit card for any and all charges incurred under the terms of this agreement.  

Cardholders Signature:_______________________________________________Date:__________________________

Please fax order form to: 202-318-2503
Email: info@cicorp.com