Simplex Data, Inc. Rebate Program

Name  _____________________________________________________________________

Address  ___________________________________________________________________

City, State, & Zip Code  ________________________________________________________

Home Phone  _____________________________________________________

E-mail Address  _______________________________________________________________

Social Security Number  ____________________________________________________

Name of Chosen Telephone Service Provider  _______________________________________

Your Monthly Regulatory Surcharge amount _______   x  12 =  ________________
(This is your one year in advance Regulatory Surcharge payment owed) 

The Registration fee for this Rebate Program must be paid in full before 

this application can be processed.

Regulatory Surcharge  payment options

1.  I am prepaying one year’s of Regulatory Surcharges in full.

Please check here  _____  

2.  I plan to make three separate payments on the total amount Owed
     (the minimum  amount that can be mailed in is $20).  I realize that 

       the amount owed  must be paid in full before any rebate funds will be mailed out.

Please Check here  ___________

Date:  __________________   Signature:  ____________________________

Mail this form  and your check to: Simplex Data, Inc., Rebate Dept. A-1,

 P.O. Box 29077,  Chicago, Illinois  60629