CPNI Authorized Person Form

By completing the form below you authorize the 3rd part listed to make inquiries regarding my Northern Telephone account concerning call details, billing, and general account information. This includes permission to make changes, and add services, to my account. Note: Capital Credits and other membership privileges, such as voting, belong only to the member(s) listed on your account. This permission does not change that. If you want to change actual ownership of your account (i.e. add a spouse), please fill out the Add A Spouse to Your Account form.

Your Account Billing Name(Required)

First Last

Your Billing Telephone Number(Required)

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Authorized Person Name(Required)

First Last

I give my written permission to allow this person listed below to make inquiries regarding my Northern Telephone account concerning call details, billing, and general account information. This includes permission to make changes, and add services, to my account. Note: Capital credits and other membership privileges, such as voting, belong only to the member(s) listed on your account. This permission does not change that. If you want to change actual ownership of your account (i.e. add a spouse), please call us.

Authorized Person Phone Number(Required)

Authorized Person Address(Required)

Street Address Address Line 2 City State ZIP Code

Please State Your Approval to Authorize the Person Above(Required)

Title (if a corporation, LLC, partnership, or trust)

Date(Required)

Comments

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