Residential Long Distance Service Application

Print the Residential Long Distance Service Application, Fill Out, Sign and Mail or fax.

NAME______________________________________________________________________________________________
EXACTLY AS IT APPEARS ON YOUR LOCAL PHONE BILL


STREET ADDRESS____________________________________________________________________________________

CITY________________________________STATE___________________________ZIP____________________________

BILLING PHONE_(______)__________________________
ADDITIONAL PHONE_(______)__________________________

LOCAL EXCHANGE CARRIER___________________________________________________________________________

PREVIOUS LONG DISTANCE CARRIER___________________________________________________________________
The undersigned hereby agrees to the terms and conditions of this agreement for service. Subscriber acknowledges that this agreement for services is subject to approval by UniDial, Inc. Subscriber hereby authorizes UniDial, Inc. to verify all listed information for credit purposes. I hereby appoint UniDial Inc. as my primary long distance carrier for equal access service. I understand that I may designate only one long distance carrier for each telephone number and that my local company may assess me a charge for this change. I authorize UniDial Inc. to make arrangements with my local company to coordinate this agreement, which may be revoked at anytime upon written notification. Some restrictions may apply.

RATE PLAN .....A7R... OR... B3R.... (CIRCLE ONE) .... B100 FOR INTRASTATE

AGENT .....NORTHWIND COMMUNICATIONS.........SALES REP. .....WEB SITE

AUTHORIZED SIGNATURE___________________________________________________DATE_______________________

PRINT AUTHORIZED SIGNATURE___________________________________________________

YOU SELECT

A7R= 12.9 ANYTIME, ANYWHERE INTERSTATE
B3R= 9.9 EVENING/WEEKEND...19.9 DAY (8 a.m. to 5 p.m.)



NORTHWIND COMMUNICATIONS
2300 HOMEWOOD DRIVE LOUISVILLE, KENTUCKY 40223
502-244-1234 FAX 502-244-5798 E-MAIL art@northwind.win.net
1-800-510-1764



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