On Call Central

On Call Central Standard Services Agreement


I am an authorized signer for .

Rate

I agree to the rate of $100.00/account every four weeks, which includes one provider. I understand that each additional provider within the account will be billed at a rate of $50 every four weeks. Additionally, I agree to a one time non-refundable setup fee of $50/provider, and that this setup charge will occur approximately concurrent with the signing of this agreement. I have reviewed and accept the On Call Central service agreement and privacy policy.

I have provider(s) who will use On Call Central.

Launch Date

Note: We try to launch new accounts on Monday, Tuesday and Wednesday, so as to avoid new client launches headed into the weekend.

I would like my On Call Central service to start on

I understand that this will be the date from which my 14-day trial will begin, and that failure to submit the necessary setup materials will not extend the duration of the trial. 

On Call Central Phone Number

The preferred area code for my On Call Central phone number is .

Preferred Payment Method

Billing Address

 

If Paying By Credit Card

Card Type

 

If Paying By ACH

Bank Name:

Account Name:   

Account Number:

Routing Number:   

Leave this empty:

Signature Certificate
Document name: On Call Central Standard Services Agreement
Unique Document ID: decafdcf47032bb847c857a5e566c9f0f287507b
Timestamp Audit
2017-08-07 12:14:51 ESTOn Call Central Standard Services Agreement Uploaded by Sidney VanNess - sidney@oncallcentral.com IP 216.68.162.250