CompanyThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Work PhoneEmail(Required) Account NumberMessageMember Consent(Required)By submitting this form, I agree to comply with the terms of the average payment plan. I understand that the amount I am to pay is figured by taking an average of my last 12 months billing history. The newest bill is always included in the average and since it is figured each month, it is a variable average which will fluctuate as does my usage. I also understand that I must pay the full amount of the average listed on my bill and by the due date. If payment is not received in full by the due date, my account is subject to being removed from the average payment plan and I will be required to pay the full actual balance owing on my account at that time. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Member Signature (Full Name)(Required)
