Online Service Request Form

Class of Service *

Residential

Business

Account Name *

Full Name *

Contact Phone Number *

Type of Service Requested

Telephone

Internet

Brazos Telephone Number

If you have telephone service with Brazos please provide your number.

FIBER Internet

DSL

10.0Mb/2.0Mb

25.0Mb/3.0Mb

OtherOther

Primary Contact Information

Full Name *

Employer

Brazos Telephone Number

Email *

Date of Birth *

SSN *

DL# *

Cell/Contact Number *

Business Tax ID#

Spouse or Secondary Contact Information

Full Name/Secondary Contact

Employer/Secondary Contact

Date of Birth/Secondary Contact

SSN/Secondary Contact

DL#/Secondary Contact

Cell/Contact Number/Secondary Contact

Service Address (911) Information

Service Address *

City *

State *

Zip *

Billing Information

Billing Address *

City *

State *

Zip *

Homestead Type *

Own

Rent

Lease

Landlord Information

Full Name

Phone #

Cell #

Type of Structure

Residential

Business

OtherOther

Type of Business

Radio Buttons *

Corporation

Partnership

Sole Proprietorship

OtherOther

Membership Information

Membership Name *

Businesses Only

Please designate ownership/authorized person:

Businesses or Residential - Please list any additional authorized

Full Name

Add Remove

Member Signature

Clear

*A copy of the Brazos Telephone Cooperative, Inc. Bylaws and the Brazos Internet Agreement will be mailed to you.

Date

Email *

Primary Contact Information

Spouse or Secondary Contact Information

Service Address (911) Information

Billing Information

Landlord Information

Type of Business

Membership Information

Businesses Only

Businesses or Residential - Please list any additional authorized

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