APPLICATION FOR PHONE SERVICE

Instructions: Be sure to complete, sign and date this application as well as read, agree, sign and date the "911 Disclaimer" document and the "Summary of General Terms & Conditions" agreement.

Applicant's Full Name: *

Service Address (Address, City, State, Zip) *

Mailing Address (If different from Service Address)

Home Phone:

Cell Phone:

Other Contact Phone:

E-Mail Address:

Date of Birth (used to verify account): * +

Social Security # *

Driver License / ID # *

BEC Communications Account #: *

* Phone Service is only available for Fiber Customers

Continue to use existing phone number/s? *

Yes

Please check the box below if you have a hearing or speech disability or condition and that this disability/limitation prevents your ability to communicate over voice networks.
More information regarding customers with disabilities

Please describe the nature of the disability or medical condition: Please describe the nature of the disability or medical condition:

I, the undersigned, do hereby acknowledge and agree to the provision set forth above. The prices listed above do not include any taxes or, when applicable, regulatory fees. The prices listed above also are not promotional nor contractual. To my knowledge the information given above is correct.

Signature of Applicant: *

clear

Date: * +