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Speed Dialing Request Form

Fill out the following form to request Speed Dialing service.

Enter phone number(s) to which you would like the service added:

--(XXX) XXX-XXXX

Select code preference: 
(if you select "Mid-Rivers pre-established codes," a Mid-Rivers Representative will contact you for the list of telephone numbers)

Select Speed Dial list size: 

Enter start date of Speed Dialing service:  mm/dd/yy

First Name:

Last Name:

Organization/Company:

Street Address:

Address (continued):

City:

State:

Zip/Postal Code:

Member Number:

Home Phone:

Work Phone:

Current E-mail Address:


To verify your submission please type in the text you see above:


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