Broadwing Association Program Long Distance Order Form

If you have questions or need more information please call 1.866.JOIN.BRW.

Step 1. Contact Information
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Daytime Phone Number:
*Email Address:
	*We would like your email address to send you automatic verification that your order has been received.
What type of account?	Residential Business Affinity Association

Step 2. Choose a Long Distance Option
	300 minutes for $19.95/month*
	500 minutes for $29.95/month*
	1000 minutes for $64.95/month*
	6.9¢ per minute for $6.95/month
	*6.9 cents¢ per additional minute. Limited time offers. Certain restrictions may apply.

Step 3. Identify the phone numbers you would like us to assign to your primary carrier
Telephone Number (1):
Telephone Number (2):
Telephone Number (3):

Step 4. Read the disclaimer
I authorize Broadwing Communications, LLC. to act as my/our agent to inform the local telephone company that I have selected Broadwing Communications, LLC. to provide my/our primary long distance service and make all arrangements with local telephone companies and long distance carriers to obtain Customer Service Record information. I understand that there may be a charge from my/our local telephone company for changing my/our long distance carrier and I understand that I may select only one long distance service provider for each line. I certify that I am authorized to request this change. I fully certify that I accept payment responsibilities for the service established with Broadwing Communications, LLC. and the invoices will be mailed to the address indicated on this form.
	I have read and accept the disclaimer.
Please select the services that you wish to transfer to Broadwing:
	Inter-Lata
	Intra-Lata
	International
	Toll Free

Step 5. Would you like to learn more about other Broadwing services?
	Calling Cards - Reach family and friends for great rates, even when you are away from home.
	Personal 8xx Service - You can set up an 8xx number that rings to your home. Perfect for encouraging kids and friends to call you.
	Conferencing Service - Set up a conference call to bring together family and friends from around the country or the globe - all on one call.
We will be happy to send you additional information about these services. If you wish to speak to someone right now about the options and rates, please call 1.866.JOIN.BRW.

Step 6. How did you find out about Broadwing?
	I am part of an Association that does business with Broadwing
	Association Name:
	Association Abbreviation (if applicable):
	I have a friend or family member that works at Broadwing
	Name of Broadwing Employee:
	My employer does business with Broadwing
	I found Broadwing on the Internet
	Other:

Step 7. Electronic Signature Information
Your First Name:
Your Middle Name:
Your Last Name:
Your Birthdate:	January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Today's Date:	January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2004 2005