CATV Service Request Form
Phone Number_______________________
Name: ____________________________________
Service Address ____________________________________
Billing Address:: ____________________________________
City: ____________________________________
State: Iowa
Zip: ____________________________________
Social Security #: ____________________________________
Employer: ____________________________________
Previous Telephone #: ____________________________________

Cable TV ~ Monthly
__________ 322- Basic Cable $23.50
__________ 323-HBO $9.00
__________ 324-Cinemax $9.00
__________ 325-HBO/Cinemax $16.00
__________ 330-Installation $35.00
__________ 331-Reconnect $25.00


Agreement
In making this Application, the undersigned agrees to the rules and regulations of Interstate Communications as set forth in this tariff and Communications Policy, and to the general changes in rules or rates for the service furnished under this Application.
Applicant's Signature: _________________________________
Application Taken By: _________________________________ (emp initials)
Date: ___________/__________/___________