Cordova Telephone Cooperative
P.O. Box 459 Cordova, AK 99574
(907) 424-2345
Fax (907) 424-2344
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MEMBERSHIP NAME: ___________________________________________________
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MAILING ADDRESS: ____________________________________________________
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PHYSICAL LOCATION OF CONNECT: _____________________________________
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DATE OF BIRTH: _____________ SOCIAL SECURITY # _______-_____-_________
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DRIVER’S LICENSE – STATE ______ NUMBER ______________ RACE _________
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EMPLOYER: ________________________________ EMPLOYMENT DATE _______
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OCCUPATION: ______________________________ CONTACT PHONE # ________
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CLOSE RELATIVE: ________________________________ RELATIONSHIP _______
- ADDRESS: ______________________________________ PHONE #
______________
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(Mailing Address including City, State and Zip Code)
(Area Code & Number)
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OWN ____ RENT ____
LANDLORD’S NAME _______________________________
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CO-MEMBER/SPOUSES NAME ___________________________________________
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ADDRESS IF DIFFERENT ________________________________________________
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DATE OF BIRTH ___________________ SOCIAL SECURITY # _________________
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DRIVER’S LICENSE – STATE ______ NUMBER _____________________________
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EMPLOYER __________________________________ EMPLOYMENT DATE ______
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OCCUPATION
________________________________ CONTACT PHONE # _______
YES
/ NO Have you had previous telephone service with CTC?
YES
/ NO If so, is there an outstanding balance on that account?
If a Service Call
is required; I understand I will be billed at the hourly rate
($62.50/hr)
for time and materials.
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