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Application Form in PDF Application Via Internet
All enter fields must be filled in. If not aplicable, please enter N /A.
申し込み日:Application date: / /
氏名: Name:  
E-mail Address:
請求書送付先: Billing Address:
Street Apt# City
Zip Code
自宅電話番号: Home Phone #: 携帯電話番号: Cellular Phone #:
xxx-xxx-xxxx xxx-xxx-xxxx
運転免許証番号: Driver’s License #: *1 生年月日:Date of Birth: *1
または OR
パスポート番号: Passport #: *1 ビザ番号:Visa #: *1
または OR
ソシアル セキュリティ番号: Soccial Security Number: *1  
Local Phone Company:
Long Distance Carrier:

現在ご家庭でご利用の電話会社をご記入ください (例: Qwest や Verizon など)。
PIC Code:
現在ご家庭でご利用の長距離電話会社をご記入ください (例: AT&T や Sprint など)。
*1ID として、免許証番号と生年月日、またはパスポート番号とビザ番号、あるいはソシアルセキュリティ番号のいずれかを必ずご記入ください。
Note *1: Either Driver’s License # + DOB or SSN is required as an ID.
家庭の固定電話 Fixed Phone at home
Phone Number(s) to register:
Phone #: 2nd Phone #: (if you have)  

■ 日本の固定電話への通話は 4.9¢(日本の携帯電話への通話は 15.99¢)、州外長距離電話 (70 マイル以遠への国内長距離通話 - Inter-LATA) は 4.9¢になります。コーリングカードを使用してローカルのアクセス番号経由で発信した場合、日本へ固定電話へは 4.49¢、州外長距離電話は 3.9¢になります。
4.9¢ to Japan fixed phone. Calls to cellular phone is 15.99¢. Inter-LATA (in-state long distance over 70 miles and to continental 48 states) is 4.9¢. If a call is made through the local access number using your calling card, a discount of 1¢/min is applied to the above prices.

  • ローカル長距離電話 (市内フリー圏外から 70 マイル圏内への州内長距離通話 - Intra-LATA 12¢(WA)、13¢(OR) (このサービスをご利用になりたい方はチェックマークをご記入ください。)
    Intra-LATA (12¢ to local long distance within 70 miles beyond the free local call area. This rate is for WA. Ask for us for other states.) (Enter check mark here if you want to also use Airnex service even for the Intra-LATA calling area.)
携帯電話 Cellular Phone
登録する携帯電話番号: Cellular Phone Number:  
携帯電話会社名: Wireless Carrier:  
■ 日本への国際電話 5.49¢ (日本の携帯電話への通話は 17.49¢)および米国内通話 4.9¢。ローカルのアクセス番号経由で発信した場合は、日本への国際電話は 4.49¢、日本の携帯電話への通話は 16.49¢、州外長距離電話は 3.9¢になります。
International call to Japan fixed phone is 5.49¢. Int'l call to Japan cellular phone is 17.49¢. U.S domestic call is 4.9¢ except Alaska and Hawaii. If a call is made through the local access number, a discount of 1¢/min is applied to the above prices.
後払いコーリングカード Post-paid Calling Card
Name on the Calling Card:
PIN Number:
Type of Card:

世界中で使用 (Global)
米国のみで使用 (US domestic only)

■ 通話料金は携帯電話と同じです。
Same international and domestic rates as cellular phone plan are applied.
契約条件 (Terms and Conditions)
I, the undersigned, as the authorized person to change the long distance service on the lines above, hereby agree to the following: (1) Airnex Communications shall provide long distance services on the lines above and act as my agent in all matters related to providing long distance services; (2) local carrier shall charge a one time fee to change the long distance carrier: (3) I shall make faithful payment to Airnex Communications for all usage of the services, regardless of the nature of the usage, i.e., who used the service, when and where the service was used, and for all federal, state & local taxes and surcharges: (4) I authorize Airnex Communications to verify the credit information provided hereto; (5) if I fail to make payment when due, a finance charge of 1.5% per month to be levied and if Airnex Communications' collection attempt is not successful, the credit card above shall be charged with a fee of 5% of the total amount; (6) when the account is past due, Airnex Communications, at its sole discretion, may increase the rates and switch to billing through the local carrier, (7) if the collection fails due to cancellation of the credit card or dispute of the charge and if subsequent collection attempt is not successful, or if the deposit is applied towards payment and a balance remains unpaid despite Airnex Communications' subsequent collection attempt, a collection procedure by a collection agency including legal action and reporting of derogatory credit record with an international credit bureau shall commence; (8) my actual usage of Airnex Communications service shall constitute my confirmation of the Agreement hereof ; (9) this Agreement shall be in full force until canceled in writing; and (10) I shall not hold Airnex Communications, its underlying carriers and agents liable for any damage resulting from using the services.