For Office Use Only:
Name:
Certificate #_________ Date:_________
Address:___________________________________ Date Installed:____________SO#________
Map #_________ SS# his_______________ hers_______________
Telephone #_______________________________________ _______________________________________________________________________________________________
The undersigned (hereinafter called the "Applicant") hereby applies for membership in and agrees to take telephone service and or other related services from the Western Iowa Telephone Ass'n. (a Co-operative) (hereinafter called the "Co-operative") and further agrees to the following terms and conditions: 1.Make a written application for membership. 2.Agrees to purchase services from the Co-operative in accordance with established tariffs and as hereinafter specified. 3.Agrees to comply with and be bound by the Articles of Incorporation and By-laws of the Co-operative and any rules and regulations adopted by the Board of Directors. 4.It is expressly understood that all amounts paid by the Applicant in excess of operation costs and expenses of the Co-operative are furnished by him as capital and he shall be credited with the capital credits so allocated as provided in the By-laws. 5.The applicant, by becoming a member, assumes no personal liability or responsibility of any of the debts or liabilities of the Co-operative, and it is expressly understood that his private property is exempt from execution for any such debts or liabilities.This application is made in consideration of similar applications by others and is understood to be an agreement with such applicant.The acceptance of this application by the Co-operative shall constitute an agreement between the Applicant and the Co-operative and shall continue in force until termination as specified in Article 1, Section 7 of the Co-operative By-laws. FOR JOINT MEMBERSHIP WITH RIGHT OF SURVIVORSHIP We, the undersigned, hereby request in our joint names as joint tenants with full rights of survivorship and not as tenants in common and agree that all capital credits which may be hereafter credited to or be due such membership shall be held by us as joint tenants with full rights of survivorship and not as tenants in common and the same may be paid by the Co-operative to either or the survivor of us.
Dated: Signed:
Printed Nam:
Signed: Printed Name:
FOR INDIVIDUAL MEMBERSHIP Membership is requested in the name of the undersigned, only. Please print your name here and sign below:
Signed:
Dated: