Account Information Update

Full Name*

First NameLast Name

Last 4 of SSN or EIN*

Account Number

Mobile Number*

Format: (000) 000-0000.

Email Address*

example@example.com

Service Address/911 Address*

City*

State*

Zip Code*

County*

YesNo

Billing Address*

City*

State*

Zip Code*

IMPORTANT MESSAGE ABOUT YOUR CUSTOMER PROPRIETARY NETWORK INFORMATION (CPNI)

The protection of your account information has always been important to our company and so has the opportunity to provide you with excellent customer service. We ask that you read the following information carefully. The Federal Communication Commission (FCC) has imposed rules on all telecommunications providers. These rules require that we obtain verification from you before we can provide you any information on your billing account.

Customers requesting information in person will be required to provide a photo ID

Customers requesting information over the phone will be required to provide us with the account passcode (see below for establishing a passcode for your account).

Customers not able to provide the required verifications above, will only be allowed to receive their account information through the USPS, Phone, or Email address of record provided below.

Account Name (as it will appear on your WCTA bill)*

If you are married and would like a joint account, please include your spouse's name here.

Provide a passcode or PIN number to verify your identity when contacting the WCTA office or NetINS Tech Support. *

If you are a business account, please provide this information to the person(s) within your company that require access to your account information

Phone Number of Record*

Please enter a valid phone number.Format: (000) 000-0000.

Email Address of Record*

example@example.com

If your account is listed only in your name, you might want to consider adding another name, if appropriate, e.g., a spouse, children, or roommate. If you are a parent or individual who relies on someone else to discuss account changes, payments or anything else with our company, you will need to have that person’s name added to your account. The name does not need to be added to the billing name, but it can be added to our records as an authorized person for discussing information and making changes to your account. The additional contacts(s) that you authorize will not be listed in the telephone directory, be responsible for payment of this account, or be entitled to any of the capital credits or voting privileges associated with this account.

Yes, I would like to add the following as authorized contacts for my account.No, I do not want to add any additional authorized contacts to my account.

Authorized User #1's*

Authorized User #1's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Authorized User #1's Email

example@example.com

Authorized User #1's Relationship*

Full AccessInquire OnlyTechnical Contact

YesNo

Authorized User #2's*

Authorized User #2's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Authorized User #2's Email

example@example.com

Authorized User #2's Relationship*

Full AccessInquire OnlyTechnical Contact

YesNo

Authorized User #3's*

Authorized User #3's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Authorized User #3's Email

example@example.com

Authorized User #3's Relationship*

Full AccessInquire OnlyTechnical Contact

YesNo

Authorized User #4's*

Authorized User #4's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Authorized User #4's Email

example@example.com

Authorized User #4's Relationship*

Full AccessInquire OnlyTechnical Contact

Signature

Today's Date

Time

Hour Minutes

AM/PM Option

Customer Information

Customer Notice on Account Privacy

Additional authorized contacts