Please fill in the appropriate information, sign the form and return to the following address:

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

Member #__________

I,____________________ have requested that toll
             (Name)

bar service be placed on my telephone number_________.

I understand that this feature will prevent 0+ and 1+ calls

from being placed from this telephone line without the use

of the PIN. This feature will also eliminate dialing "0" to reach the

operator. I also release Mid-Rivers Communications from

any liability resulting from the inability to place such a toll call

from my telephone, and assume all liability connected with the

inability to make toll calls from my telephone.

______________________________
(Signature)

_____________________________
(Date)