Resident Telephone Credit Application If you are a new customer, the following form must be completed & submitted. Thank you!Resident InformationResident Name *SSN *0 / 9Phone *Email Address *Resident Spouse NameSpouse SSN0 / 9Spouse PhoneSpouse Email AddressPhysical (E911) AddressStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Directory ListingIs this listing non-published?YesSchool DistrictNumber of people in household: *Mailing Address if DifferentMailing AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeEmployer InformationEmployer NameEmployer PhoneEmployer Street AddressSuiteEmployer CityEmployer State/ProvinceEmployer ZIP / Postal CodeHow long at employer?PositionPersonal InformationAre you or your spouse:62 years of age or olderHandicappedDisabled(Check all that apply)Do you receive any of the following forms of assistance?Aid to Families with Dependent ChildrenSNAPLow Income Home Assistance ProgramMedicaidSupplemental Security IncomeVeterans Disabilities PensionVeterans Surviving Spouse PensionI am not receiving assistance from these programs, but I meet the financial eligibility requirements of 135% of the Federal Poverty Guidelines (FPG).Chazy Westport may request a copy of your benefits card.Nearest Relative Not Residing With YouRelative NameRelationshipRelative Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCustomer & Security InformationHave you previously had service with Chazy Westport Communications or Westelcom? *YesNoCPNI (Customer Proprietary Network Information) *Select oneFavorite PetSports TeamFirst CarName of Pet *Name of Team *Make and Model of Car *Important Authorization InformationRecent government changes give you a new choice about how Chazy & Westport (C&W Tel) uses information about your current telephone service to continue our efforts to meet your communication needs.What information are we talking about?Certain information regarding the telecommunications services that you purchase from C&W Tel. This includes the types of services that you receive and your calling patterns, specifically what areas you call and the hours of the day you choose to call.How can we use this information to help you?C&W Tel. will be able to use this information to let you know about the services that you may not realize are available to you. By knowing your calling patterns, C&W Tel can customize packages that may make sense for you to take advantage of. These services can include long distance, calling features, cellular, various internet services, and much more. You will be able to enjoy saving as well as make communicating much more convenient. However, new governmental regulations require us to get your approval first.Who will use this information?Only C&W Tel and the Westelcom Family of Companises will use this information. We will not sell or give this information to other companies.Please indicate below whether you authorize us to review your account and make you aware of the communication opportunities that we can offer you, now and in the future.Yes! I give my authorization for C&W Tel to use information about my current services to inform me of other services that C&W Tel and Westelcom Companies provide.Your Name *Your typed name will serve as your signature.Date *Subscriber Telephone Number *Please Note:When you click onto the SUBMIT button below you will be taken to the 'Fiber Application' form that must also be completed. Thank you! Chazy WestportSubmit