Form A—Customer Information
C
B
USTOMER
ILLING
C
C
USTOMER
P
T
ERSON TO BE
S
P
/A
ALES
ERSON
CCT
G
C
ENERAL
ONTRACTOR
(only required if new construction)
I
A
NSTALLATION
I
D
NSTALLATION
UE
N
I
OTES TO
NSTALLER
F
I
EATURES OF
NTEREST
(list in order of priority)
S
V
ERVICE
ERIFICATION
V
ERIFIER
I
NSTALLER
N
:
AME
:
ONTACT
:
RAINED
E
:
XEC
:
:
DDRESS
D
:
ATE
:
:
:
Provide the name of the telephone service representative who verified your service and the date the
This is not required for all installations. See next page for details.
service was verified.
N
:
AME
N
:
AME
PARTNER
B
P
N
:
ILLING
HONE
UMBER
C
P
N
:
ONTACT
HONE
UMBER
T
P
N
:
RAINEE
HONE
UMBER
S
/AE P
N
:
ALES
HONE
UMBER
C
P
N
:
ONTRACTOR
HONE
UMBER
D
V
:
ATE
ERIFIED
D
I
:
ATE OF
NSTALLATION
®
Advanced Communications System
0
Form A—Customer Information
1