Qwest LETTER OF AGENCY
(Authorization to Change Commercial Service Long Distance Carrier)
Revised: 9/2/1999
Page 1 of 2
CUSTOMER INFORMATION SALES INFORMATION
Account ID: Sales Rep Name: DialTone Management, Inc
Order Sign Date: Sales Rep ID: 29EF
Orion/CORE Order #: Sales Rep Phone Number: 847-995-1000
Bill Cycle: Sales Support Rep: Debbie Lynch
Type of Change: New Add to Account Admin. Change Partial Disconnect
The undersigned customer wishes to switch its current long distance service to Qwest Communications Corporation (“Qwest”). Qwest is hereby
designated to act as the undersigned customer’s agent for the purpose of: (1) notifying customer’s local telephone company of the selection of Qwest as
its primary interexchange carrier (“PIC”), and (2) ordering, in connection with Qwest’s provision of service, changes in and/ or maintenance on specific
telecommunications service including, without limitation, adding to or rearranging such telecommunications service(s).
The undersigned customer’s selection of Qwest will apply only to the telephone number(s) listed below. The undersigned custom er hereby
designates Qwest as its primary interexchange carrier for the following long distance services (Customer MUST initial one of the following
service types as appropriate):
____ interLATA (including international and intrastate) and intraLATA services; or
____ interLATA (including international and intrastate) services only; or
____ intraLATA services only.
Unless otherwise expressly agreed to in writing, Qwest shall have no obligations or responsibility to arrange for termination or removal of
telecommunications services provided by long distance providers. The undersigned customer shall remain responsible for terminating and
removing any such unwanted services and circuits provided by other long distance providers.
NOTICE REGARDING USAGE-RELATED INFORMATION
In the course of providing service to you, we will possess certain usage-related information about the quantity, type and destination of
telecommunications services you use. You have a right, and we have a duty, to protect the confidentiality of this information. This information may be
useful to tailor our products and services to your needs and to enhance our ability to meet all of your telecommunications needs. With your approval,
we will use your usage-related information to offer you other Qwest (or its affiliates) products or services that may satisfy your needs and to respond to
your concerns if you have become dissatisfied or cancel any of our services. Of course, your decision will not harm the quality of service Qwest (or its
affiliates) provides, and we will honor your choice until you expressly tell us otherwise.
_______ I authorize Qwest or its affiliates, or its agents to use billing and usage-related information related to my account to see if I
would benefit from other telecommunications services offered by Qwest, its affiliates, or its agents, and market them to me.
I understand that my local exchange carrier (LEC) may charge a fee of approximately $5.00 per line to change long distance carriers. I represent that I
have the authority to change communications carriers for each of the numbers identified below and that I am at least eighteen (18) years old. I
understand that I may designate only one primary interexchange carrier for any one telephone number for state-to-state (interLATA), intrastate, and
international usage; and that I may designate only one primary interexchange carrier for any one telephone number for intraLATA usage (where
applicable). With these understandings, I select Qwest to provide the communications service types indicated above for each of the telephone
numbers listed below.
Signature (required) Date
Company Name: Multiple Page LOA
Page of _______
(Customer Initials)
Contact:
Title:
Service Address:
City: State: Zip Code:
Phone Number: Fax Number:
Comments:
Telephone Number(s) to be PIC’d BTN(s) Affected by This LOA
# of Index Bill-to How is this BTN currently billed for Local Service?
Who will contact LEC? Telephone # PAC Code Digits Number (Owner/Company Name, City, State)
Qwest Cust V NV
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Version: CMS18003
Qwest LETTER OF AGENCY
(Authorization to Change Commercial Service Long Distance Carrier)
Revised 9/2/1999
Page 2 of 2
Orion/CORE Order ID: Account ID:
Customer Name:
Additional Telephone Numbers to be PIC’d
Who will contact # of Index Bill-to How is this BTN currently billed for Local Service?
LEC? Telephone # PAC Code Digits Number (Owner/Company Name, City, State)
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Comments:
Version: CMS18003