SULLY TELEPHONE ASSOCIATION
APPLICATION
FOR SERVICE
NAME_______________________________________SS#_______________________
911 ADDRESS_______________________CITY___________STATE___ZIP CODE________
BILLING ADDRESS____________________________________________________________
NAME OF OTHER ADULTS LIVING AT THIS ADDRESS____________________________
RACIAL/ETHNIC GROUP (REA REQUIREMENT)
(A) WHITE (NOT OF HISPANIC ORIGIN) _______
(B) BLACK (NOT OF HISPANIC ORGIN) _______
(C) HISPANI _______
(D) AMERICAN INDIAN OR ALASKAN _______
(E) ASIAN OR PACIFIC ISLANDER _______
PREVIOUS TELEPHONE COMPANY_____________________________________________
PREVIOUS TELEPHONE NUMBER__________________EMPLOYER#_________________
PRESENT EMPLOYER__________________________________________________________
CREDIT REFERENCES BANK________________________________________________
BUSINESS____________________________________________
INTERLATA(outside 641 area only)
INTRALATA(inside 641 area)
STA 3A plan____STA 4A plan_____
STA 3A plan____STA 4A plan___
STA 6 _________OTHER_________
STA 6________OTHER__________
TOUCHTONE____CALL WAITING____CALL FORWARDING___3-WAY CALLING____
SPEED CALLING 8____UNLISTED#_____900 BLOCKING____EQUIP.RENTED_________
INTERNET______________CALLER ID_________
DEPOSIT_____EQUIPMENT CONNECTION$30.00 TOTAL AMOUNT DUE_______
Any information falsely given in this form to obtain telephone service may result in the immediate termination of your telephone service and further legal action to fairly compensate Sully Telephone Association for service rendered. If you do not have established credit the deposit amount will be determined by the rules and regulations established by the Iowa Commerce Commission. I have read and fully understand the above.
Date____________Signature________________________________________________
Phone#_________________Cable Pair_____________________LCE_____________________
Revised 12/2/2003