Electronic Signature Form – Phone Letter Of Agency

Phone Letter Of Agency (LOA)

Step 1 of 5

A signed Letter of Agency (LOA) is required by LymeFiber in order to provide service to the end user. This completed LOA must be on file before LymeFiber can request information about current services with other providers. LymeFiber’s Customer Service Record information shall include all terminal numbers, and billing name and address, end user usage and service information and the contact name and address for each end user location designated by the undersigned.
This Letter of Agency gives legal authorization to LymeFiber a) to act as your agent to make any and all inquiries necessary for the purpose of obtaining Customer Service Records information, and b) to act as your agent for the purpose of taking any and all actions required (including the removal of any account protection / freezes) to become your LOCAL SERVICE PROVIDER and to implement other services described herein for all your physical services and billing locations as noted on this form including changing your long distance carrier(s). PLEASE ONLY LIST THOSE NUMBERS YOU WISH TO SWITCH.
This authorization does not preclude our ability to act on our own behalf when we deem necessary to do so.
If you would like to opt out of this electronic signature form, please click the following link "Opt out and Print". *When you click the link it will automatically download. Please check your devices downloads to print the LOA. Once you have filled out the form you can either scan and email the LOA to Support@LymeFiber.net or mail it to PO Box 323, S. Royalton, VT 05068
Consent*
I authorize LymeFiber or its authorized designee to review my account information, assess current services and assist in making modifications to my account throughout the duration of my agreement. I give LymeFiber the authorization to notify all appropriate parties, including my current local and long distance carrier of choice and to make the necessary changes for my current and future services without further permission. LymeFiber may obtain any records from my local intra-lata long distance, and / or long distance Telephone Company necessary so that they may provide these services to me.
- I agree to the terms below.

Name on account with LymeFiber*
First Last
Email
Address Where LymeFiber Service Is Physically Located*
Street Address Address Line 2 City New Hampshire ZIP Code

Current Phone Provider*
Name of Current Phone Provider*
Contract Fees With Your Current Provider*
I understand that I am responsible for any early contract termination fees levied by my current phone provider (I.e., Fairpoint/Consolidated, Comcast, Exede, Wildblue, WaveComm etc).
- I Agree
Name On Account With Current Phone Provider*
We must provide the name of a person on the existing account who is authorized to make changes to that account.
First Last
Pin If Other Than FAIRPOINT/CONSOLIDATED
Providers other than Fairpoint/Consolidated require us to provide them with the Pin (or Passcode) in order to switch a number to our service. This is usually on bill next to or below account number.

Please provide the phone number you would like to transfer.*
Do you have more than 1 number you would like to transfer?*
- Yes
- No
2nd number to transfer

I agree to the Electronic Signature*
The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
- I Agree
Draw Your Signature Into The Box Below.*