Application for Telephone Service/L.C.
Today’s Date: Service Request Date: .
oBusiness oResidential Louisa Communications Number:______.
oInside Wiring Agreement ($2.50/month) o900 Number Block
oUnlisted Number ($.25/month)
Billing Information
First Name: Last Name: Middle Initial: .
Mailing Address: .
Street Address: .
City: State: Zip Code: .
Telephone Number______
Social Security Number or Federal Tax ID: .
Long Distance Carrier
oAT&T oMCI oSprint oTMC oLouisa Comm Plan 4a
oTCC oLDDS oWiltel oMcleod oLouisa Comm Plan 3a
oTelecom USA oAllnet Comm oMetromedia oExcel
oNational Teleservice oOne Star oNYNEX oOncor Comm
oFrontier oBell Atlantic oMidCom oTelco Comm
oCoast International oQWEST Comm oCable & Wireless
Features I want on my Telephone Line
Description Fee Description Fee
oCalling Party Identification $4.00 oCall Waiting $1.50
oToll Code Authorization $5.00 oCall Forwarding $1.50
o8 Number Speed Dial $1.50 oThree Way Calling $1.50
o30 Number Speed Dial $2.50 oVoice Mail $3.75/$4.50/$5.25
No fee will be charged to add features at this time. To add features to your line at a later date there is a $20.00 service order charge.
Installation Terms
There is a $50.00 new service installation fee for all new installations. This fee does not include inside wiring or restoration work. These fees are additional and will be explained at the time of installation.
Low-income assistance is available to eligible recipients. Would you like more information? oYes oNo
Yes, I understand the installation terms as stated above. Signature: .
Recurring Charges Office Use Only
Line 1 / Price / Line 2 / Price / Line 3 / Price / Line 4 / Price / Line 5 / Price / Line 6 / PriceNonrecurring Charges
OCC / Price / OCC / Price / OCC / Price / OCC / Price / OCC / Price / OCC / PriceApplication Taken By .
LSR______Port______Masters 911 Switch INS______Directory______
REMARKS
Site______LCC______
Shelf______Pair Number______
Card______Pair Color______
Circuit______Binder Color______
OE/Len______