Application for Service

Pennsylvania Telephone Company
191 Middle Rd.
Jersey Shore, Pa. 17740

Date:

Name:

Address:

County:

Social Security Number:

Previous Address:

Previous Telephone Number:

Employer:

Previous Customer of this Company:

Type of Service Requested:


Required.



Lycoming      Clinton









Yes      No



     The undersigned makes application for telephone service of the kind and class as described above and agrees to pay the rates as established for such service; and further agrees to the Rules and Regulations as set forth in the exchange tariff and to any general changes in the rules, regulations, tariffs or rates for such service. The application becomes a contract when accepted in writing by the Telephone Company.