JURISDICTION (AREA):	Intra-State____	Inter-State____
	(In State)	(Out of State)

PLAN:	Traditional ____	R-Plan ____
	(no monthly fee)	(3.95/month, reduced per min. rates)

I understand that the long-distance service will apply ONLY to the telephone numbers listed below at the address indicated below. I also understand that only one long distance company, per jurisdiction indicated, may be designated for each telephone number. My local telephone company may charge a fee per jurisdiction to switch my long-distance service.

_____________________________      _____________
Authorized Signature:                                    Date:

_____________________________
Name: (Please Print)

Telephone Number: (_____) ___________________

Additional Phone Number(s) (To Have RNS Long Distance) ___________________ ___________________

PIN Number for Calling Cards: __________ (4 digits) Number of Cards: ____

Residential Address: ___________________________________________________

City, State, Zip Code: ___________________________________________________

Mailing Address: ___________________________________________________
(if different)

Name of Business or Company Requesting Service: ________________________

Referred By: ____________________________ Phone #: ________________

Do you currently have long distance service? ____Yes  ____No

Do you Currently have a PIC freeze ?____Yes ____No

Mail Form To: Rural Network Services -PO Box 167– Weiser ID 83672
Or Fax: 208-414-2603
Questions? rnsinfo@ruralnetwork.net     Contact Us At: 208-414-3000 or 888-355-4767