Online Service Request Form Call Brazos Communications at 1.800.687.3222 or fill out this form to request service. * Required fields 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 25Mb/25Mb 50Mb/50Mb 100Mb/100Mb 1GB/100Mb OtherOther 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 * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Billing Information Billing Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 * Membership Type * Single Joint Business Partnership OtherOther 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 * Submit