I authorize Uni-Tel Communications Group, Inc. DBA Global Unitel, to notify my local telephone company that I am choosing Unitel as my primary carrier for long distance service. I understand that I can have only one primary carrier for this service per telephone number listed on this form, and my local telephone company may apply a small fee for this and any other charge. A switching charge may be incurred each time the underlying interexchange company is changed. I also appoint Uni-Tel Communications Group, Inc., to act in our name and stead, to coordinate all present and future telephone lines/numbers at all locations that are under my control for the provisioning of long distance service. In addition, this appointment of agency gives Uni-Tel the authority and right to: Issue instruction to and otherwise deal with the local exchange company and/or long distance company. To obtain duplicate copies of customer records, telephone bills, and any other information Uni-Tel requires. This authorization shall remain in effect until further written notice. Customer shall be billed on a monthly basis. Customer shall pay the invoice by the due date stated on said invoice. If payment is not received by the due date customer shall pay a late fee in the amount of 1.5% of the unpaid balance per amount or the maximum lawful rate under applicable state law. Uni-Tel reserves the right to designate or assign this service agreement to any subsequent providers or to any other carriers providing service and changing underlying carriers.

AUTHORIZATION GIVEN BY:

Name (print):____________________________________________________________
Signature: ________________________________ Date: _______________________

CUSTOMER NAME AS IT APPEARS ON LOCAL PHONE BILL:

Name (print):_____________________________________________________________
SSN or FIN #__________________________________ (Required for credit check)
Mailing Address: ______________________________ Apt/Suite#________________
City: ____________________________ State:_____________ Zip:_______________

Install Address (if different):_______________________ Apt/Suite#_________
City: ____________________________ State:_____________ Zip:_______________

Main Billing Number:  (_____)___________________
Second Number:        (_____)___________________ 
Third Number:         (_____)___________________
Fourth Number:        (_____)___________________

I would like to switch to UNITEL for Intralata Calls:    YES______  NO_______

Estimated Monthly Usage: $________________

TOLL FREE SERVICE

Use this section if you want to order toll free service from UNI-TEL

Existing 800/888/877 number:  (_____)___________________ 
Rings-to:                     (_____)___________________

Would you like to have a NEW 800, 888 or 877 number:  YES______  NO_______
Ring-to number: (_____)___________________