IMAGINE NETWORKS LOA

Please provide your name as it appears exactly on your current telephone provider bill:

Name

First NameLast Name

Organization or Company Name

Please provide the Service Address (Please note, this must be a physical address, PO Boxes are not permitted) for 911 Service:

Address

Suite, Apartment, Unit, etc

City

State

Zip/Postal Code

Telephone Number With Area Code

Current Telephone Service Provider

Port Out PIN

I authorize Imagine Networks LLC or its designated agent to act on my behalf to:

Notify my current carrier(s) to change my preferred carrier(s) for the listed number(s) and service(s) To obtain any information that is deemed necessary to make the carrier change(s) including but not limited to: an inventory of telephone lines billed to the telephone number(s), carrier or customer identifying information, billing addresses, and my credit history. I also acknowledge: This form has been completed to the best of my ability and knowledge The name, address, and company name if applicable I have provided are the ones on record with my current telephone service provider(s) I verify that I am, or represent the above-named telephone service customer, authorized to change the primary carrier(s) for the telephone number(s) listed above I am at least 18 years of age That I must keep all numbers in service with my current carrier until the port completes to avoid delays or rejections I am responsible for any termination charges imposed by my current carrier for porting my number(s)

Authorized Signature

Printed Name

Date