Sprint Customer Authorization Form Pre-Qualification of Line for RGV DSL Service

Rockbridge Global Village

312 South Main Street, Lexington, VA 24450

Phone: 540-463-4451 Fax: 540-463-4451 ext 104

Customer Information

Name:
Address:
City:	State & ZIP:
Contact Phone:	Fax:
Email:

Phone Number to Inspect for Conditioning (Requesting DSL Service Line)

Phone Number:

Location/Address of Phone Line:

There will be a non-refundable charge by SPRINT of $33.56 for this required process.

Customer authorizes Rockbridge Global Village, Inc. (RGV) and Sprint to obtain subscriber service information on the above listed phone line in order to determine possible pre-conditioning requirements for DSL service.

RGV will provide information to the Customer as to the exact requirements and additional costs, if any, for conditioning the above listed phone line in order to properly receive DSL service, which will be provided by RGV.

Customer Signature:	Date:
Customer Printed Name:	Date: