PREFERRED CARRIER FREEZE AUTHORIZATION

(Must be signed by person responsible for the Monon Telephone Company Inc.Ò account)

I hereby request and authorize Monon Telephone Company Inc.Ò to freeze the Preferred Carrier on my account on each of the following services as of this date. I understand I will not be able to change my carrier selection unless I lift the freeze. I understand there is (not) a $__charge to initiate and terminate this service, and that there will be a charge to change carriers.

Local Telephone Service _______________________________(signature)

IntraLATA Toll Service ________________________________(signature)

InterLATA Toll Service ________________________________(signature)

International Toll Service _______________________________(signature)

ACCOUNT NAME __________________________________(please print)

Address ____________________________________________

Telephone Number(s) __________________________________

Driver License Number or Tax ID Number _______________________

Date _______________________