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MOVE SERVICE TO NEW LOCATION

(Failure to complete ALL sections completely could delay the processing of your order)

Outside Move Charges:



Residential $24.25 and Business $31.25.  Plus, cost of any jack installations as indicated below.




*  Required

Current Account Information:



*  Name: 
*  Current Account # or Phone Number:  
*  Daytime Contact Phone Number:  
Fax Number:   
E-Mail Address:   




New Account Information:

New Service Address:
(Physical Location - No Post Office #'s)
Name:
Address:
City:County:
State:Zip:
Inside City Limits?YesNo



Billing Address:
(If different from Service Address)
Name:
Address
City:
State:Zip:



Date of Birth:

I grant Public Service Telephone Company permission to enter and cross said property for the purpose of installing and, if necessary, repairing telephone service.

How many people live in this residence?Please List Names:

Directory Listing:
(If different from Service Address)
Name:      
Address: