Complete and Return to:
Coon Creek Telephone Company
312 Locust Street NE
PO Box 150
Blairstown, IA 52209-0150

If you have any questions, feel free to call us at: (888) 823-6234 or (319) 454-6234

This letter authorizes CCTC to request and receive data and billing information and to act as our representative for telecommunications. CCTC is authorized to notify our local and long distance telephone company of our telecommunications choices for the telephone number(s) listed on this form. This authorizes CCTC to acquire our telephone number(s) listed below for the purposes of joining our telephone number(s) with their shared services.

We agree to pay all charges prior to CCTC's acceptance of our local telephone service and any additional charges sill applicable.

DATE___________ SIGNATURE______________________

Please Type Or Print ____________________________ Customer Name ____________________________ Street Address/City/County/State/Zip ____________________________ Customer Billing Address (if different than above) ____________________________ Customer Name as it should appear in the directory	I would like my number to be unlisted in the directory I would like an additional/alternate directory listing Please check the following additional services you would like to subscribe to. We will contact you and/or send you the appropriate forms. Internet Access Voice Mail E-mail Pager Service 800/888 Numbers Calling Cards
_(___)_____________________ Current Telephone Number	YES. I would like to change to the new exchange prefix. No. I wish to retain my current telephone number(s)
_(___)______________________ Additional Telephone Number(s) ____________________________ ____________________________ Intralata Long Distance Carrier ____________________________ Interlata Long Distance Carrier	PLEASE CHECK THE FOLLOWING CALLING FEATURES YOU WISH TO SUBSCRIBE TO: Each Custom Calling Feature shown is offered at a monthly cost of $1.00 each except for 900 Toll Blocking which is no charge. 3 Way Calling (Conference) Call Waiting Call Hold/Call Forwarding Accept Call Forwarding Busy Call Forwarding No Answer Call Forwarding Variable Caller number ID Do Not Disturb Speed Calling Wakeup Call Last Number Redial 900 Toll Blocking is N/C Wire Maintenance Other(list)_____________