Residential Application for Service

Within the City of Burlington

(Call to confirm availability at your location)

Plains Communication Services, LLC

6488 US Highway 36, Joes, Colorado 80822

(voice) 970-358-4211 (fax) 970-358-4505

(email) plains@plainstel.com (website) www.plainstel.com

Current Telephone Number *

Will you be moving an existing telephone number to Plains? *

Yes Yes

Name of Applicant *

0/50 characters

Date of Birth

Social Security # *

Service Address, City, State, Zip *

Mailing Address, City, State, Zip *

Previous Address, City, State, Zip *

Employer and Work Phone # *

Cell Phone # *

Nearest Relative Not Living with Applicant, Phone #, Address, Relationship to Applicant *

Signature *

clear