Residential Application for Service

Within Burlington, Bethune & Stratton

(You can call to confirm availability at your location if we can't confirm over the phone we'll have a technician do a site survey free of charge.)

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?

It's important that you don't disconnect any existing service until you have spoken with us. We’ll walk you through the process. If you want to keep your existing number to transfer (port) it to Plains for service, the number must be active. A disconnected number is not available for porting to Plains and will be lost. *

Yes Yes

Name of Applicant *

0/50 characters

Date of Birth

Social Security # *

Drivers License State and # *

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 *

Everything that I have stated in this application is correct to the best of my knowledge. I authorize Plains Cooperative Telephone Association, Inc. to check my credit history with Online Utility Exchange and to answer future questions about its credit experience with me. (The amount of the deposit which may be required of an applicant for the purpose of establishing credit is $250-$500 based on credit history). Note: All personal information Plains Cooperative Telephone Assn. accumulates pertaining to your account is available to you, the applicant, at any time.

Plains Communication Services, LLC, service is for a minimum of 24 months following installation (i.e. the commitment period). If service is disconnected before the commitment period is complete, a $200 service charge will apply. A $25 late fee will be assessed when bill is 30 days past due.

Signature *

clear