2014-132 ES - Windstream for radio circuit

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APPLICATION FOR CREDIT Representative: Smith,Brian T w i n ds t re a m. Representative Phone: 919-719-5024 Customer Name: Orange County Tax Exempt Status: Federal Tax ID or SS Number: EMR: $707.00 Billing Address: 510 Meadowlands Dr Years In Operation: Number Of Employees: City: HILLSBOROUGH State: NC Zip: 27278-8504 Business Structure: Nature Of Business: Company Name: Address: City: State: Zip: Contact Name: Dinah Jeffries AP Contact Name: Contact Phone: 919-245-6123 AP Contact Phone: Contact Fax: AP Contact Fax: Contact Email: AP Contact Email: Principal/Partner/Officer Full Name: Title: Bank Name: Address: Bank Contact Name: City: Bank Contact Phone: State: Bank Contact Fax: Zip: Account Number: n or Account Number Phone Fax Contact 1. Address: 2. Address: 3. Address: Current Local Telco: Current LD Carrier: Authorization t r I hereby represent that 1 am authorized to submit this application on behalf Signature: of the Customer named above,and the information provided is for the purpose of obtaining credit and is warranted to be true. lMe hereby Printed Name: W;2-V)C"o authorize Company,and its affiliates to investigate the references listed pertaining to my/our credit and financial responsibility sold. I further Title: �Q Q, represent that the customer applying for credit has the financial ability and willingness to pay for all invoices with established terms. Date: a