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.

Business Name: *

Contact Name: *

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

Mailing Address (If different from Service Address)

Business Phone: *

Cell Phone:

Other Contact Phone:

E-Mail Address:

Federal ID# *

BEC Communications Account #: *

Continue to use existing phone number/s? *

Yes

I, the undersigned, do hereby acknowledge and agree to the provision set forth above and have the authority to enter into this agreement on behalf of the business referenced above. The prices listed above do not include any telephonetaxes or, when applicable, regulatory fees. The prices listed above also are not promotional nor contractual. To my knowledge the information given above is correct.

Name of Authorized Individual: *

Date: * +

Signature of Applicant/Authorized Individual: *

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