LONG DISTANCE SERVICE FORM Untitled Yes I choose Nortex Long Distance, you must autorize us to switch your current long distance carrier to our service. Yes I choose Nortex Long Distance to carry my local toll calls (InterLATA) If you are interested in switching to Nortex Long Distance, you must authorize us to switch your current long distance carrier to our service.Name Physical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Sign me up (choose one)(Required)Select an OptionResidential- Unlimited minutes- $20/moResidential- 500 minute plan- $13/moResidential- 100 minute plan- $5/moResidential- 12 cents/minute- no monthly feeBusiness- 8 cents/minute- $5/moBusiness- 12 cents/minute- no monthly feePrimary Number(Required)Phone NumberPhone NumberPhone NumberBy electronically signing below, I am authorizing Nortex to become my new residential provider of long-distance service and/or local toll service (if available and selected by me). I authorize Nortex to act as my agent to make this change happen, and direct my local company to work with Nortex to affect the change. I understand I may consult with my current carrier as to whether a fee will apply to change to my preferred carrier. If I later wish to return to my current telephone company, I may be required to pay a reconnection charge to that company. I also understand that Nortex may have different calling areas, rates and charges than my current provider, and that by signing below I indicate that I understand those differences (if any) and am willing to be billed accordingly. I authorize Nortex to provide long-distance and/or local toll service to my telephone numbers listed above and no others. I certify that I have read and understand this Letter of Agency. I further certify that I am at least eighteen years of age, and that I am authorized to change telephone companies for services to the telephone numbers listed above. I understand that I may select only one interLATA (long-distance) carrier and only one intraLATA (local toll) carrier for each telephone number. I am responsible for all valid Nortex charges for all usage. Existing Nortex customers will assume responsibility for any domestic or international rate changes that occur through submission of this order. I understand that this application is subject to credit review. I consent to the use of electronic records for the purposes as listed in this letter of agency. Your Nortex order will be processed within 3-5 business days. After this time period, should you choose to return to your previous carrier or another carrier, please contact Nortex. You may call us 940-759-2251 to confirm that your long distance and/or your local toll service has been switched to Nortex as requested. If would like to switch to Nortex Long Distance but do not want to fill out this form, please contact us 940-759-2251. Businesses interested in Nortex Long Distance need to call us at 940-759-2251.Last Four SS#(Required) Signature(Required) CAPTCHA