Long Distance Form(LOA)

Long Distance Letter of Authorization
Name*

First NameLast Name
Address*

Street Address

Street Address 2

CityState

Zip Code
I understand that I may choose only one (1) Inter-LATA and one (1) Intra-LATA long distance company for each telephone number.
Phone Number*
Must enter 10 digits
Additional Phone Number
Must enter 10 digits
Pic Freeze Request/Authorization
Phone Number*
Must enter 10 digits
Additional Phone Number
Must enter 10 digits
I understand that there is no charge for this service, and that I will be unable to change carriers unless my “PIC Freeze” is removed at my request.
By submitting this form. You agree for Randolph Communications to update your long distance.
Electronic Signature

By typing and signing below, you agree that this is an electronic signature.
Name*

First NameLast Name
Signature with mouse/finger/stylus:*

Clear
Date*

MonthDayYear
Date
Should be Empty: