Application for Service

Cooperative Service Area: Anton & Lindon, Cope, Eckley, Idalia, Joes, Kirk, Seibert & Vona

Service in this area begins with our great local landline service. You'll become a member of our cooperative with your landline phone service and you'll immediately begin earning capital credits based on your service.

Add the Internet service package that

meets your needs for the full telecommunications experience!

Plains Cooperative Telephone Association, Inc.

6488 US Highway 36, PO Box 123, Joes, Colorado 80822

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

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

Name of Applicant *

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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 shall be the amount of an expected ninety days toll and sixty days local service - $235.00). Note: All personal information Plains Cooperative Telephone Assn. accumulates pertaining to your account is available to you, the applicant, at any time.

Signature *

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