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GLANDORF TELEPHONE CO., INC.

  135 S. Main St .

Glandorf , Ohio 45848-0031

419-538-6987

PERMISSION FOR DIRECT PAY

  I  give permission to Glandorf Telephone Co., Inc. to withdraw money from my savings/checking account on a monthly basis to pay all charges due them for the current month.   I understand I will continue receiving a monthly bill.  However, I will NOT receive a written receipt. I also understand this transaction will take place on the 10^th of each month.

BANK INSTITUTION NAME_______________________________

BANK ROUTING NUMBER________________________________

ACCOUNT NUMBER ____________________________________

Savings ________                 Checking __________

TELEPHONE NUMBER___________________________________

DATE  ________________________________________________

SIGNATURE ___________________________________________