Please print this form, then fill in the appropriate information, sign it and return it to the following address:

Mid-Rivers Telephone
Attn: Customer Services
PO Box 280
Circle, MT 59215

Member #:____________

Mid-Rivers Telephone Co-op. Inc.

(NO MONTHLY CHARGE.)

PLEASE RESTRICT MY TELEPHONE NUMBER FOR:
(Please mark each line that applies with an X.)

________ No Direct Dialed 900 Number Calls Allowed

________ No Third Number Billed Calls Accepted

________ No Collect Calls Accepted

________________________
Signature

________________________
Date