Permission to Give Information

If you would like to give permission to another person to have access to your account, please return this form to our office after you have completed and signed the form below. When this form has been returned to our office, we may then give out information to the person(s) assigned below.

My Name

I give Western Iowa Telecom permission to give any information on my account to the person(s) named below. The representative(s) are authorized to receive and inspect confidential telephone information and to perform an and all acts that I (we) can perform with respect to telephone matters, such as authority to sign any agreements, consents, or other documents. The authority does not include the power to receive refund checks or the power to substitute another representative unless specifically added below.

Printed name

Signature

Address

Street Address City State

Phone

Printed name

Signature

Address

Street Address City State

Phone

Printed name

Signature

Address

Street Address City State

Phone

The above named person(s) will not be held liable for payment on my account, or for any charges on my account, and will not have any share in the capital credits my account may accrue.

Account holder's signature or business name*

Telephone number

Date

Please list anyone who is currently a contact person whose name you would like removed from the list of current contacts on this account:

Email

This field is for validation purposes and should be left unchanged.

Wiatel Headquarters

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