FAX APPLICATION FORM

Complete the application and fax to 281. 362.8105.

NAME:_________________________________________.

ADDRESS:_______________________________.

CITY:_________________________. STATE:____________. ZIP CODE: _________________.

HOME PHONE#:______________________.

SOCIAL SECURITY#:_____-_____-_____. DATE OF BIRTH:_________/__________/__________.

DRIVERS LICENSE#:_______________________________.STATE:_____________________.

EMPLOYER:__________________________________________.

PHONE#:_____________________.

HOW LONG: _________yrs POSITION:_____________________________.

SPOUSE:________________________________________. SPOUSE WORK#:___________________________.

ADDRESS IF ABOVE LESS THAN TWO YEARS:

_______________________________________________________.

CITY:________________________.STATE:_______________.ZIP CODE:_______________________.

RELATIVE NOT LIVING WITH YOU:___________________________________________.

ADDRESS:____________________________________________________________________.

CITY:_____________________________.STATE:_____________. ZIP CODE:___________________.

PHONE#:_________________________________.

I AUTHORIZE ANY RDI REPRESENTATIVE TO CHECK MY CREDIT IN ORDER TO PROCESS THIS APPLICATION

SIGNATURE:______________________________________. THIS____DAY OF ________________, 20 _____.

CELLULAR PHONE# (IF APPLICABLE):_______________.

(TO TRANSFER CURRENT RATE PLAN TO RDI RATE PLAN) REFERRED BY:_______________________________.