PERSONAL AND SERVICE INFORMATION

First Name: *
Last Name: *
Date of Birth: (MM/DD/YYYY) *
Form of Identification: *	----Drivers LicenseSocial Security Number
Identification Number: *
Phone Number (e.g.: XXX-XXX-XXXX): *
Current Long Distance Carrier: *
Service Address: *
Service Address:
City: *
State: *	----California
Zip Code: *
Email Address: *
Best time to call: *	8 a.m. - 11 a.m.  11 a.m.- 2 p.m.  2 p.m. - 5 p.m.
Please type the letters and numbers shown in the image.

NOTE

The person who prepares this form states that he or she is the person, executor, guardian, authorized officer, or agent of the person for whom service would be established under this order. Anyone submitting false or inaccurate information on this form is subject to punishment by fine or imprisonment or both.  TCAST Communications cooperates, to the fullest extent, with law enforcement and regulatory agencies in order to keep our customers information secure and safe. This service is available to new TCAST customers only. Per minute and bundled rates do not include taxes or surcharges.