Please enter the required fields below before submitting the form. If you wish to mail in the form, you may download a copy of this form to be printed and completed.
Person to Whom Exempt Telephone Number is Billed
(if other than Applicant)
This section is to be completed ONLY by the certifying authority
The Certifying Authority must be a reputable professional whose knowledge of the specific circumstances is generally accepted and acknowledged and/or an authorized employee acting for and on behalf of a special school, institution, or other recognized entity whose knowledge under the specific circumstances is generally accepted and acknowledged.
NOTE: The facts in this application may be reviewed periodically by Midcontinent Communications.