Application for Membership and Service FacebookThis field is for validation purposes and should be left unchanged.Type of Service: Residential Business Government Agency Legal Name First Last Social Security Number/Tax IDDate of Birth Month Day Year Driver’s License NumberStateBilling Name Same as legal name aboveBilling Name: First Last Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical/911 Address Same as Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In City Limits Yes No CityCountySpecial Instructions (animals, gate code, etc.)Primary Contact NamePrimary Contact NumberText Capable Yes No Backup Contact NameBackup Contact NumberText Capable Yes No Email Address Automatic Bill Payments Yes No Paperless/E-Billing Yes No Preferred Interexchange Carrier (PIC/LD)PIC Freeze Yes No Inside Wire Maintenance ($1/mo) Yes No Directory Listing? Yes No ($1/mo if unlisted) Directory Name First Last Directory Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you authorize Eastex to responsibly use your account information (CPNI) to determine if we have products or services that may benefit you? Yes No Please provide a username for your account(8-50 characters, +1 numbers, +1 letters, special character)Please provide a PIN for your account(4 or more numbers/characters to verify your account when contacting our office)Please answer the following “secret” questions (used to verify your identity when speaking with customer service)In what city was your mother born?What is your favorite color?What is your favorite sports team?What is your mother’s maiden name?What is your favorite car, truck or motorcycle?You may add an individual(s) as an authorized user(s) of your account, enabling them to obtain call detail information or make changes on your behalf. Any individual you authorize on your account will need to know the answers to the security questions you have provided above. Authorized User #1 Name First Last Authorized User #1 PhoneAuthorized User #2 Name First Last Authorized User #2 PhoneTerms and Conditions1. The Applicant will pay a membership fee of $10.00, plus installation fees. 2. The Applicant will subscribe to telephone service, from the Cooperative, to be used on his or her premises, and will pay rates as determined by tariff and the bylaws of the Cooperative. 3. The Applicant will grant to the Cooperative a right-of-way easement to construct, operate and maintain a telephone line or system on the Applicant’s property and in or upon all streets, roads or highways abutting said property. 4. The Applicant will comply with and be bound by all provisions of the charter and bylaws of the Cooperative, and such rules and regulations as may from time to time be adopted by the Cooperative. 5. The Applicant, by becoming a member, assumes no personal liability or responsibility for any debts or liabilities of the Cooperative and it is expressly understood that the Applicant’s private property is exempt from execution for any such debts or liabilities. 6. The Applicant agrees that the Cooperative, or its designee, is expressly authorized to investigate any references and other information furnished by the Applicant or by any other person or entity, pertaining to the Applicant’s creditworthiness. The Cooperative may, at any time, and at its sole discretion, revoke the privilege of extending credit to the Applicant for future telephone services. 7. The Applicant agrees that this Application and any tariffs, terms and conditions, or other documents incorporated herein by reference (e.g. the Charter and Bylaws of the Cooperative) will be construed under the laws of the State of Texas and that venue will be fixed in state district court in Rusk County, Texas for the resolution of any and all types of claims or conflicts between Applicant and the Cooperative. 8. If any clause or provision of this Application is found to be invalid or is incapable of being enforced by any rule of law or public policy, all other clauses and provisions shall, nevertheless, remain in full force and effect. I hereby apply for membership in and agrees to take telephone service from Eastex Telephone Cooperative, Inc., a Cooperative, non-profit corporation existing under the laws of the State of Texas for the purpose of furnishing telephone service, upon the following terms and conditionsCustomer Electronic Signature (Full Name)Please enter your full name First Last Business Title
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