Application for Service

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

Residential service in this area begins with our great local landline service, which is a requirement to go along with the broadband service in our cooperative area. 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 *

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 understand that in order to receive Plains Broadband service, I will also be billed for Plains local voice service if I am within Plains cooperative area. 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 $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.

Signature *

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