Qwest | Large Business | Authorization to freeze preferred service provider(s)

Authorization to freeze preferred service provider(s)

For your protection, use of this form requires you to provide an Account Passcode. If you do not currently have an Account Passcode, you can establish one by calling your Sales Representative or 1-800 777-9594. You can also Freeze your services via fax or email using a Letter of Authorization available from your Sales Representative or 1-800-777-9594.

All orders submitted after 3pm CST will be processed the following business day.

* indicates a required field

Subscriber's Name (Must be exactly as it appears on current bill): *

Subscriber's Address (Must be exactly as it appears on current bill): *

City: *

State: *

Zip: *

Account Passcode *

The undersigned Subscriber requests to "freeze" their Preferred Service Provider(s) for the following service(s).

LEF
Local Service
(Dial tone Service)
(Not Available in AZ,MN,NE,NM,IA,MT)

LPIC
Local Long-Distance or Toll Service
(1+ IntraLATA service, Local In-state Long-Distance)

PIC
Long-Distance Service
(1+ InterLATA service, State to State)

Marking the box adjacent to the identified Service(s) is a separate request from, and authorization by, the undersigned Subscriber to Qwest to freeze the Preferred Service Provider of the service(s) for the telephone number(s) below. Please select your desired freeze preference(s) adjacent to the telephone number(s). The Subscriber may choose one, two, or all of the freezes. The Preferred Service Provider that is frozen will be the current one for the particular service and number as of the date this document is presented to Qwest. The undersigned Subscriber understands that no change in such a provider can be made unless that freeze is lifted, even if the authorization to change the Preferred Service Provider is in writing or verified by a third party.

Only the telephone numbers listed below are covered by this "Freeze" Authorization.

Subscriber's Main Telephone Number
LEF LPIC PIC

Additional Telephone Numbers
LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC	LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC LEF LPIC PIC

The phone number(s) listed on this Authorization are listed in my name and/or I am authorized to freeze the Preferred Service Provider for the phone number(s) set forth above. By pressing the "Submit" button as described below, I am personally signing and dating this form, certifying all of the information on this form, and authorizing Qwest to freeze the current preferred service provider(s) for each designated service on each such designated phone number. I understand that I may lift this freeze: (a) by calling Qwest at the toll free number listed at the top of my Qwest telephone bill and orally authorizing Qwest to lift the freeze, including providing appropriate verification, or (b) sending Qwest a written or electronically signed authorization to lift the freeze. I understand there is no charge associated with implementing or lifting the freeze(s) included in this Authorization.

By clicking on the submit button, you are electronically signing and dating this Letter of Authorization, authorizing the freeze(s) described above.

Type Name:

Type Title, if applicable:

Type Date (MM/DD/YY):