Change Of Name Or Ownership Change Form (Page 3 of 3) in pdf

Change Of Name Or Ownership Change Form Page 3

NVC-1000-50-01

Change of Ownership & Customer Credit Application

July 1, 2008: Revision I

Page 3 of 3

NUVOX RESERVES THE RIGHT TO REQUEST A COPY OF (a) THE COMPANY’S MOST RECENT FINANCIAL

STATEMENT AND (b) THE REMITTANCE PORTION OF THE INVOICE FROM THE COMPANY’S PREVIOUS OR CURRENT

TELECOMMUNICATIONS CARRIER.

I understand that the information contained in this application is presented for the purpose of obtaining credit in

connection with the provision by NuVox of telecommunication and/or information services. I hereby certify that I am

an officer of the Company named on the front page of this application, that I am duly authorized to provide the

information contained herein on behalf of the Company, and that the information contained is true and correct to the

best of my knowledge. I hereby authorize NuVox Communications to obtain credit information from any credit

bureau or other investigative agency pertaining to the credit and financial responsibility of the Company. I further

understand as a result of the credit review, NuVox may decline to provide its services to Company or the Company

may be required to submit a deposit, payment authorization form (auto-pay) for a 12 month period or other

assurance of payment before NuVox will agree to provide services to Company. All services provided by NuVox to

Company will be provided pursuant to NuVox’s service agreement terms and conditions.

_______________________________________________________

Company Name

_______________________________________________________

Type or Print Name and Title of Owner or Officer

_______________________________________________________

Authorized Signature

Date

Please fax to 864-335-5913.

Change Of Name Or Ownership Change Form Page 3