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BILLING APPLICATION FOR COMPUTER REPAIR SERVICES
Organization Name:
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Authorized Person:
@{ form.errors.get('authorizedPerson') }
Contact Number:
@{ form.errors.get('phoneNumber') }
Email:
@{ form.errors.get('email') }
Billing Address:
@{ form.errors.get('billingAddress') }
City:
@{ form.errors.get('billingCity') }
State:
Select A State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
@{ form.errors.get('billingState') }
Zip:
@{ form.errors.get('billingZip') }
Tax Exempt:
Yes
No
@{ form.errors.get('taxExempt') }
Include Certificate if Exempt
Existing PBC Customer:
Yes
No
@{ form.errors.get('existingCustomer') }
Account Number:
@{ form.errors.get('accountNumber') }
Please add repair charges to our monthly phone bill.
Please set up a separate billing account for repair services.
@{ form.errors.get('bill') }
Repair Shipping Address:
@{ form.errors.get('shippingAddress') }
City:
@{ form.errors.get('shippingCity') }
State:
Select A State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
@{ form.errors.get('shippingState') }
Zip:
@{ form.errors.get('shippingZip') }
Security Q&A
Security question (This is a question that our staff can ask an authorized person):
@{ form.errors.get('securityQuestion') }
Security answer (should be at least 4 letters or digits):
@{ form.errors.get('securityAnswer') }
Authorized Personnel
I give the following people listed here the authorization to make changes / inquiries to our Paul Bunyan Communications Account. I understand that these people will need to know the security answers to make changes / inquiries. I also understand that it is my responsibility to notify Paul Bunyan Communications of any changes to the Authorized Persons list.
Name:
Phone:
@{ form.errors.get('authorizedPersonnel') }
W-9:
Additional Files:
Signature:
@{ form.errors.get('signature') }
Submit
I agree that any transactions or agreements with Paul Bunyan Rural Telephone Cooperative dba Paul Bunyan Communications or its associated companies may be formed by electronic means.
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×
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×
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