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The Customer hereby authorizes Mench Media and its upstream provider to act on behalf of the Customer to make changes to the Customer's existing local phone service with respect to Local Number Portability, limited to the numbers listed below. The Customer hereby authorizes Mench Media and its upstream provider to port/disconnect the indicated local telephone numbers from the Customer's existing local phone service provider.

BILLING INFORMATION

SITE INFORMATION

Customer Trading / Operating Name

Site 1 Address (include suite, floor unit)

Customer Name (as it appears on the local phone bill if different)

Site 2 Address (include suite, floor unit)

Company Address

Site 2 Address (include suite, floor unit)

City

Prov/State

Postal Code

Site 4 Address (include suite, floor unit)

CUSTOMER TELEPHONE NUMBERS TO BE PORTED:

(ranges of numbers are acceptable - consecutive numbers only)

Current Provider Name

Telephone Number

Name of Signatory

Title

Date