Information Request Form For Pole Attachments, Conduits and Right-of-Way

The following information is needed to complete a Pole Attachment, Conduit and Right-of-Way Agreement between your company and TDS Telecom. Please complete the information as soon as possible and submit so your agreement can be processed in an expeditious manner.


    If negotiating multiple agreements, please complete one form for each state. Please enter the name of the state in which the agreement/contract is to be effective in the space below:

    State:


    The following information must be provided and certified as correct by a duly authorized Officer or Attorney of the business entity(ies) in the agreement (collectively the "Contracting Party").


    The exact legal name(s) of the Contracting Party which will be legally bound by the agreement and the legal form of that entity:

    Name:

    (d/b/a, if any): 

    Legal Form (i.e. corporation, partnership, etc.):


    The name and business title of a duly authorized Officer of the Contracting Party with execution authority to bind the Contracting Party:

    Name: 

    Title: 


    The street/mailing address of Contracting Party's principal place of business:

    Street Name: 

    City:  State: Zip:

    Telephone Number: - -

    Facsimile Number:   - -


    The state in which the Contracting Party is incorporated:


    The name and streeet address of individual or department authorized to receive bills and payments for Contracting Party:

    Name:

    Street Name: 

    City:  State: Zip:

    Telephone Number: - -

    Facsimile Number:   - -


    The name and street address of individual or department authorized to receive operations issues and correspondence for the Contracting Party:

    Name:

    Street Name: 

    City:  State: Zip:

    Telephone Number: - -

    Facsimile Number:   - -


    The name and street address of the individual or department authorized to received billing information (data) for the Contracting Party:

    Name:

    Street Name: 

    City:  State: Zip:

    Telephone Number: - -

    Facsimile Number:   - -


    The name and street address of the Registered Agent, or other person, authorized to receive legal notice for the Contracting Party:

    Name:

    Street Name: 

    City:  State: Zip:

    Telephone Number: - -

    Facsimile Number:   - -


    Is the Contracting Party authorized to provide services to the public in the state in which negotiation is sought?

    Yes or No


    If yes, please indicate the regulatory/legal authority and the date certification was granted:

    Regulatory/Legal Authority:

    Date Certification Granted: 

    I as (Officer's Title) /or Attorney for (Company) , the Contracting Party, do hereby certify that the foregoing information is correct.

    Signature/Name:

    Telephone Number:  - -

    Date:

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