Local Phone Service Order

For new service or transfer of existing service

11-21-2008
* required field
** Please fill out at least one of these fields.

Long Distance+:

As your local telephone service provider, Stickdog becomes responsible for implementing your selection of long distance carriers.
Please Select:

Primary (InterLATA/ PIC):
Stickdog: None: Other: If Other, please specify carrier:

Regional Toll (IntraLATA/ LPIC):
Stickdog: None: Other: If Other, please specify carrier:

I will contact Stickdog to specify different carrier selections for each phone number on my account.
Please 'freeze' my long distance carrier selections to prevent change unless I authorize Stickdog to do so.

+Primary LD carrier change subject to a $5 fee; Regional LD carrier change subject to a $5 fee.

Local Calling Features: Please select the features you would like. Leave blank for a migration 'as is' with no changes to your phone line.
Caller ID Deluxe: Call Waiting: Unlimited 3- Way Call Call Block: Call Intercept: Ultra Forward: Voice Mail (Select Areas) Wire Maintenance Plan:	Call Waiting ID (free w/ Call Waiting and Caller ID) Hunting: Unlimited Return Call Repeat Call: Call Forwarding Variable: Fixed Call forwarding Specify Number or 'Voice Mail': Distinctive Ring: Non Published Number:
Note: Local Telephone service rates include connection of the service to the Network Interface point at your building. Inside wiring is the responsibility of the customer or building owner. We can assist with this at your request at our standard rates for inside wiring.

Payment Terms:

Monthly invoicing based on calendar month. Partial months pro-rated. Payment is due upon receipt of invoice. Overdue 20 days after mail date.

Advance payment required in the following cases:

New connections
Transfer of account subject to credit treatment by Verizon
Transfer of account from carriers other than Verizon

Advance payment amount is $70 for first line plus $30 for each additional line.

Advance payment is applied against balance on first invoice
Order processing charges apply to some changes of features

No advance payment is required for transfer of account in good standing from Verizon.

AUTHORIZATION & AGREEMENT: I request Stickdog to provide telephone service to the phone numbers listed above and agree to pay invoices presented to me by Stickdog at the rates provided in Stickdog's tariffs and offer sheets. I authorize Stickdog to contact other service providers to obtain information on the accounts for the above numbers and to arrange for transfer of service on these accounts to Stickdog. I acknowledge that each telephone number may only have one primary long distance carrier and one regional toll carrier and that my local telephone company may charge a fee for changing carriers.

Personal Identifiers will be used in lieu of your signature on this online form. This information is required for processing.

Birth Month*: 2 digit Day*:(example "01") 4 digit Year*: (example 2002)
Mother's Maiden Name*:

Stickdog · 143 A Church St NW, Vienna, VA 22180. · (703) 319 1700 · Fax: (703) 319 1894 · sales@stickdog.com