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Tuesday, September 07, 2010
  SUBMIT COMPANY INFORMATION 
1. SUBMITTED BY: 2. PHONE:

3. LEGAL NAME OF COMPANY:
4. STATE OF INCORPORATION:
5. CALL DIRECTING CODE(S):   (if applicable)

6. BUSINESS ADDRESS OF YOUR COMPANY'S HEADQUARTERS
ADDRESS:
CITY:

 

ZIPCODE:
7. YOUR COMPANY'S ONE CALL ADMINISTRATIVE REPRESENTATIVE
NAME:
TITLE:
PHONE:
FAX:
EMAIL:
ADDRESS:    
CITY:  
ZIPCODE:
8. ALTERNATE REPRESENTATIVE INFORMATION (not required)
NAME:
TITLE:
PHONE:
FAX:
EMAIL:
ADDRESS:   
CITY:  
ZIPCODE:
9. BILLING INFORMATION
Bills for service will be issued on or before the 10th of the month, following the service month.
NAME:
TITLE:
PHONE:
FAX:
EMAIL:
ADDRESS:
CITY:  
ZIPCODE:
SALES TAX STATUS:
IF DIRECT PAY, PLEASE ATTACH A COPY OF DIRECT PAY PERMIT.
IF EXEMPT, PLEASE ATTACH A COPY OF EXEMPTION CERTIFICATE.

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