<< HIT THE 'P' KEY TO PRINT >> RESIDENTIAL SERVICE REQUEST FORM A.F.I. LONG DISTANCE SERVICE - SERVICE REQUEST AGREEMENT _________________________________________________________________________ NAME> ______________________________________________________________________ EXACTLY AS IT APPEARS UNDER CURRENT BILLING SOC. SEC. #> ________________________________________________ ACTUAL STREET ADDRESS [NO P.O. BOX]> CITY> STATE> ZIP> COUNTY> BILLING ADDRESS, IF DIFERENT FROM ABOVE> __________________________________________________________________________ SERVICE INFORMATION: ENTER EACH TELEPHONE NUMBER INCLUDING AREA CODE. TOP NUMBER SHOULD BE YOUR BILLING NUMBER. LIST ADDITIONAL NUMBERS ON SEPARATE SHEET IF NECESSARY. AREA CODE> NUMBER> AREA CODE> NUMBER> AREA CODE> NUMBER> AREA CODE> NUMBER> [THE FOLLOWING IS NECESSARY TO INSURE YOUR DISCOUNT] _____________________________________________________ PRESENT LONG DISTANCE CARRIER _____________________________________________________ CURRENT DISCOUNT CALLING PLAN I WOULD LIKE TO ORDER _____ TRAVEL CARDS. SERVICE AUTHORIZATION _________________________________________________________________________ With this signature I authorize Affinity Fund to change my long distance carrier for the telephone number(S) indicated. I authorize Affinity Fund to notify my local telephone company of this choice. I understand that I can have onliy one primary long distance company for a given telephone number and that my local telephone company may impose a charge for this and any later change. ________________________________________________________________________ SIGNATURE DATE ____________________________________________________________________ PRINT NAME SEND COMPLETED REQUEST FORM TO: OR FAX TO: (408) 423-0131 LIGHTHOUSE PRODUCTIONS P.O. BOX 7885 SANTA CRUZ, CA 95060 CONSULTANT ID CODE: 747-0180