Customer Name ___________________________________________

Account Name (exactly as it appears on your current phone bill) _____________________________________________________

Street Address (as it appears on your current phone bill) __________________________________________________________

City______________________________________        State ___________         Zip Code _____________________

Mailing/Billing Address (if different) _____________________________________________________________________

City______________________________________        State ___________         Zip Code _____________________

Toll Free Numbers to be Transferred

I, the undersigned, hereby authorize PowerNet Global Communications to act as my agent for the following toll free number(s):

Agreement and Waiver

• The undersigned is not an agent for any third party.
• The undersigned represents and warrants that they are the exclusive end user/subscriber of the toll free number(s) listed herein.
• The undersigned authorizes PNG Telecommunications, Inc. as agent for the appointment of responsible organization for the toll free number(s) listed herein.

I understand and agree with the above information:

Authorized Customer Signature ___________________________________________    Date _____/_____/_____

Printed Name _______________________________________________