Letter of Agency (LOA)

and Customer Service Records (CSR) Request

For each of the telephone numbers listed herein and on Attachment A, I appoint Higher Resolutions to act as my Agent for the purpose of collecting my account information with my current local telephone carrier or provider (hereinafter " Provider')

By selecting Higher Resolutions to act as my Agent to research my current services with my current Provider of local telephone service, I am authorizing the change of my local telephone Provider from that / those which I am currently using to Higher Resolutions This authorization will expire notification only

LOA Instructions:

1. Only one (1) BTN may be associated with each LOA. If you have additional BTN's, you must submit a LOA for each BTN.

2. Please provide a copy of the most recent losing carrier invoice for the BTN listed above (Must include ALL pages). The information on this LOA MUST match the attached losing carrier invoice.

3. Use Attachment A for listing all telephone numbers associated with this BTN.

Billing Telephone Number (BTN) *

Billing Telephone Number (BTN):

This information MUST match your current invoice and account information

Company Name * Address * Customer Account Contact *Title * Customer Contact Number * Losing carrier invoice *

Most recent invoice for the BTN (all pages). Upload starts as soon as you choose the file.

Continue to Attachment A

Letter of Agency (LOA)

and Customer Service Records (CSR) Request

Attachment A

List all telephone numbers to be ported in the following format with one phone number per space Do not add toll free 800 numbers or alarm lines to this LOA Use a RESPORG for toll free numbers

Additional Numbers

One number per line

Authorized Signature *

Authorized Signature:

Print Name *

Name used in Signature

Email Address *

Email Address:

Date *

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