Residential Application for Service

Within the City of Wray

Plains Communication Services, LLC

29360 US Highway 34, Wray, Colorado 80758

(voice) 970-592-2211 (fax) 970-592-2212

(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 is $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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