Toll Free Letter of Authorization

Letter of Authorization Change in Responsible Organization 1. Customer Information Billing Name (as on existing carrier bill) DBA Name (or name toll-free is listed under) Billing Street Address City State Zip Code Billing Contact Name Contact Title Contact Phone Contact Fax 2. Current Carrier Switching From 3. Toll-Free Numbers 4. Coverage for Toll-Free Numbers Above Check to indicate from which areas toll-free calls will be accepted. ☐Continental U.S. Only (Default) ☐Continental U.S. + Canada ☐Continental U.S. + Alaska/Hawaii/PR/USVI ☐Continental U.S. + Alaska/Hawaii/PR/USVI + Canada ☐Canada Only 5. Customer Authorization By signing below on behalf of Customer, I designate Impact Telecom to act as the Responsible Organization (RESP ORG: TUI01) for the toll- free numbers identified above. I authorize Impact Telecom to act as the agent for the purpose of taking such action as may be required on my behalf to implement this selection. This authorization supersedes all other RESP ORG designations pertaining to these toll-free numbers. I hereby understand and agree that I am not authorized to advertise or promote the new toll-free numbers listed above until I have received written notification from Impact Telecom that the toll-free numbers I have requested to be reserved have been officially activated. I further understand that service on any existing toll-free numbers listed above continues with my current provider until the transfer to Impact Telecom is complete. Company Legal Name Customer Signature Print Name of Signatory Print Title of Signatory Date V.x14 Existing Toll-Free Number Terminating Number for Toll-Free 1 2 3 4 5 6 7 8 9 10