Business Responsible Party Change Form

Business Responsible Party Change Form
By filling out this form I request to take responsibility for the accounts noted below and in consideration agree(s) to pay the ongoing monthly service charges and any other applicable charges, including but not limited to: current and/or unbilled phone, long distance, TV, internet, pay-per-view, directory listings, yellow page ads, digital advertising, etc., current and/or outstanding/past due balances associated with the account(s) as of the transfer date. (Long distance charges may take several months to appear on the statement.) I understand any current commitments for the service will need to be fulfilled to avoid any early termination fees if services are disconnected. I certify that the information I have entered is true and correct to the best of my knowledge. I authorize Arvig to check my credit to verify information as stated on this application.
Existing Account Information
Current Business Name*
Effective Date*

MonthDayYear
Business Owner/Contact Name*

First NameLast Name
Account Number*
Phone Number*

Area CodePhone Number
E-mail*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Services To Be Transferred
New Account Password
New Internet User ID / Login ID
Internet Accounts Only
AutoPay Active

YesNo
Are you transferring all services?

YesNo
How many service accounts are you transferring?
Enter a number
1. Service Account Number*
1. Circuit ID:
1. Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Service Account Number
2. Circuit ID:
2. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Service Account Number
3. Circuit ID:
3. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Service Account Number
4. Circuit ID:
4. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Service Account Number
5. Circuit ID:
5. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. Service Account Number
6. Circuit ID:
6. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Service Account Number
7. Circuit ID:
7. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8. Service Account Number
8. Circuit ID:
8. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
9. Service Account Number
9. Circuit ID:
9. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Service Account Number
10. Circuit ID:
10. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
11. Service Account Number
11. Circuit ID:
11. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
12. Service Account Number
12. Circuit ID:
12. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
13. Service Account Number
13. Circuit ID:
13. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
14. Service Account Number
14. Circuit ID:
14. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
15. Service Account Number
15. Circuit ID:
15. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
16. Service Account Number
16. Circuit ID:
16. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
17. Service Account Number
17. Circuit ID:
17. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
18. Service Account Number
18. Circuit ID:
18. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
19. Service Account Number
19. Circuit ID:
19. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
20. Service Account Number
20. Circuit ID:
20. Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Account Information
New Business Name*
New Account Number
Phone Number*

Area CodePhone Number
Email*
example@example.com
Business Owner/Contact Name*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any other services to be transferred
Signature of Existing Business
Signature of New Responsible Party
Signature of New Co-Responsible Party
Arvig will contact you to verify all changes you requested have been made on the account.
Should be Empty:

Business Responsible Party Change Form

Existing Account Information

Services To Be Transferred

New Account Information