Please provide customer name, phone physical address, and main telephone number.

Installation Address
Customer Name:
Street Address:	(phone location)
City:	State:     Zip Code:
Phone:	(Main telephone number on the account.)

If the bill goes to a different name and/or address than those provided above, please fill in the following fields. Otherwise, leave blank.

Billing Address
Billing Name:
Billing Address:	(where the bill goes)
City:	State:     Zip Code:
Phone:	(Phone for bill contact person.)

Select the type of account you want as well as its service range.

Account Type & Range
Type:	Residential Business Church
Range:	Both Intrastate and Interstate Intrastate traffic only Interstate traffic only

Please list any additional phone numbers that belong with this account and that you want switched to PowerNet Global.

Additional Phone Lines
Phone Number and Description:	Voice Fax Modem
Phone Number and Description:	Voice Fax Modem
Phone Number and Description:	Voice Fax Modem
Phone Number and Description:	Voice Fax Modem

Do you have an existing toll free number you wish to transfer? Please provide the following information:

"Ring to" is the number where the phone rings when someone uses that toll free number

To request a new toll free number, please fill in this form with the phone numbers for which you wish to have a new toll free number.

New Toll Free Numbers

I want a new toll free number for: I want a new toll free number for: I want a new toll free number for:

Now for a few other details yet.

Miscellaneous Information
Estimated Long Distance Bill:	(monthly)
Email Address:
Want a calling card? If so, how many?

Now please double check all your entries for accuracy.

When you click Submit below, you will receive the completed application form at the email address you entered above. Please print out that email message, sign it and fax (or snail mail) it to me. My address and fax number will appear at the bottom of that form.

Thank you for choosing PowerNet Global and Anabaptist Bookstore!