LETTER OF AUTHORIZATION
Long Distance Telephone Services
By signing below, I authorize Monon Telephone Long Distance to become the provider of long distance services for the telephone account number(s) listed below. This letter authorizes Monon Telephone Long Distance to place orders on my behalf for the provision of long distance services until otherwise revoked.
I understand that I may only designate one primary carrier for my interLATA calls (including international and interstate) and one primary carrier for my intraLATA calls.
I certify that I have the authority to make such designations on the services listed below
Mail or fax the completed form to Monon Telephone Company, Inc.® or drop off at the Monon Telephone Company, Inc.® business office.
Mail: Monon Telephone Company, Inc. Phone: (219) 253-6601 P. O. Box 625 Fax: (219) 253-7500 Monon, IN 47959 ________________________________________________________________________________________________Billing name on account: _________________________________________________________
Billing address on account: _________________________________________________________
Town & State _________________________________________________________
Zip Code __________________________________________________
______________________________________________________________________________________________________________________________________
Please check one:
Primary number to be changed: (_____) ______- __________ _____Interstate and Intrastate calls
_____Interstate calls only
Additional number to be changed: (_____) ______- __________ _____Interstate and Intrastate calls
_____Interstate calls only
Additional number to be changed: (_____) ______- _________ _____Interstate and Intrastate calls
______Interstate calls only
Additional number to be changed: (_____) ______- _________ ______Interstate and Intrastate calls
_____Interstate calls only
_______________________________________________________________________________________________________________________________________
Authorized Signature: __________________________________________________
Printed Name: __________________________________________________
Contact Telephone Number: __________________________________________________
Date: __________________________________________________
____________________________________________________________________________________________________________________________________
For Monon Telephone Long Distance: __________________________________________________