BUSINESS or PERSONAL SERVICE REQUEST FORMNAME> CONTACT> TITLE>STREET ADD> COUNTY>CITY> STATE> ZIP>BILLING ADDRESS, IF DIFERENT FROM ABOVE>CONTACT> PHONE> BUSINESS OR PERSONAL?> BUSINESS BANK> BRANCH> ACCT NO>TRADE REFERENCE1> CONTACT> PHONE>TRADE REFERENCE2> CONTACT> PHONE>PRESENT CARRIER> EST. MONTLY LONG DISTANCE BILL>FED. TAX ID> SERVICE INFORMATION: HOW MANY NUMBERS> LIST BELOW ALL PHONE NUMBERS. IDENTIFY WHICH LINES ARE BILLING TELEPHONE NUMBERS (BTN) NOTE: YOU MAY HAVE MORE THAN ONE BTN. ALSO SPECIFY LINE TYPE PER CODE: F= FAX, M= MODEM, V= VOICE.AREA CODE NUMBER BTN TYPE 1. - AREA CODE NUMBER BTN TYPE 2. - AREA CODE NUMBER BTN TYPE3. - AREA CODE NUMBER BTN TYPE4. - AREA CODE NUMBER BTN TYPE5. - AREA CODE NUMBER BTN TYPE6. - AREA CODE NUMBER BTN TYPE7. - AREA CODE NUMBER BTN TYPE8. - I hereby authorize Affinity Fund, Inc. or their authorized representative to transfer my long distance line carrier. I understand that my local operatingcompany may charge a fee to perform the transfer. I accept responsibility for all changes associated with the above telephone number._____________________________________________________________________________AUTHORIZED SIGNATURE TITLE DATE _____________________________________________________________________________PRINT NAME_____________________________________________________________________________SEND COMPLETED REQUEST FORM TO: OR FAX TO: (408) 423-0131LIGHTHOUSE PRODUCTIONSP.O. BOX 7885SANTA CRUZ, CA 95061OFFICE USE ONLY ANI CONSULTANT SIGNATURE CONSULTANT ID CODE: 747-0180
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