DSL AUTHORIZATION AND LETTER OF AGENCY (LOA)

I hereby authorize Central Oregon Internet to act as my agent in all matters relating to the provisioning of DSL service. I understand that, by signing this Letter of Agency (LOA), Central Oregon Internet will become my ISP for DSL services that Central Oregon Internet may place order(s) with Qwest on my behalf for the provisioning of DSL loop(s) between my location(s) and Central Oregon Internet.

I understand that my local phone company (LEC) will charge a fee for DSL transport or to change my DSL ISP. I represent that I have the authority to add DSL or change DSL providers for each of the numbers identified on this form and that I am at least eighteen (18) years old.

SUBSCRIBER NAME:
ADDRESS:
 
CITY: ZIP:
AUTHORIZED NAME*:
DATE: May 23, 2018
PHONE NUMBER: On which DSL is to be provisioned
QWEST ACCOUNT NUMBER: (required)               Only the last 3 digits

* The person or company in whose name telephone service is provided.
Usually, but not necessarily, this is the same as the subscriber.

Coinet Verification Code**:  

** The verification code is a unique code issued by Coinet to each DSL
subscriber. It indicates that you, and only you, have submitted this form.
If you do have a code please contact Coinet.