Letter of Agency

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Email Address *

I understand that by signing this form, I authorize Tele-Media Solutions to switch my interstate and intrastate PIC to Telemedia Solutions for the following numbers:

Phone #1 *

Phone #2

Phone #3

I further understand that my application may be subject to credit review. Tele-Media Solutions may use any information obtained from this service application or credit reporting agencies to determine creditworthiness.

Pick your plan: *500 Anytime Minutes - 24/7 for $27.50 per month - Added to your monthly bill 5.9 cents / minute - 24/7 - per minute

Additional Services

Conference Calling - 10 cents / minute 800 Toll Free Service - 6.5 cents / minute PIC Freeze - No charge (This prevents any change in your long distance carrier without your authorization) Allow International Calling (Calls to/from contiguous 48 states only. Call for international pricing rates.)

The terms and conditions governing the provision of our interstate, intrastate, and international long-distance services are set forth in our Terms and Conditions of Service document which is available for your inspection at our business office located at 105 E Railroad Street, Pekin, IN, during normal business hours (8:30 a.m. to 4:30 p.m., Monday - Friday). This information is also available on our website - www.tele-mediasolutions.coop. Your access and use of our interstate, intrastate or international long-distance service represent acceptance of the terms and conditions set forth in the Terms and Conditions of Service document. We will provide you with advance notification of changes in the document through either a bill insert or direct mail.

Signature *

Signature of authorized subscriber on account