SERVICE APPLICATION AND LETTER OF AUTHORIZATION Sales Rep: discounted

EXISTING TOLL FREE NUMBER TRANSFER (RESPORG):

The undersigned Customer hereby appoints ""Uni-Tel Communications Group""(UZL01) to act as its authorized agent for all matters pertaining to the toll-free number(s) listed below. This agency includes, without limitation, the ordering or rearrangement of service assignment of primary carrier service requests, disconnection of service and other requests as deemed necessary by Uni-Tel Communications to implement the toll free services ordered from Uni-Tel Communications.

Toll Free Number	Ring-to Number	Prior RESPORG (Carrier)

Uni-Tel Account No.: __________________________________________________
CURRENT RESP ORG/I.D. _________________________________________________
HOLDER NAME: __________________________________________________________
SOCIAL SECURITY NUMBER/ FEIN: _________________________________________
ADDRESS: ______________________________________________________________
CITY _____________________________, STATE ________, ZIP _______________
MAIN TELEPHONE NUMBER: ________________________________________________

AUTHORIZED SIGNATURE: _________________________________________________
SIGNATORY NAME (printed): _____________________________________________
TITLE: ________________________________________________________________
DATE: ______________________   DIRECTORY ASSISTANCE YES**_____  NO_____

FAX TO: 1-800-499-9581
Cognigen Agent ID: discounted
Agent Email: support @ 1plus-longdistance.com

Please include a copy of the front page of a recent bill for toll free service

© 2005 Cognigen Networks, Inc. All rights reserved.