CHICAGO STATE UNIVERSITY
OFFICE OF TELEOCMMUNICATIONS
STUDENT RESIDENT HALL
TELEPHONE SERVICE APPLICATION
Date of Request______________________
Length of Service Requested_______________
Name_______________________________
(Last)
______________________________________
(First)
(M.I.)
Home Address ________________________________________________________________
(Not CSU)
___________________________________________________________________________
(City)
(State)
(Zip)
Home Phone
_______________ -- ______________ -- _________________________
Soc. Sec. Number _______________ -- ______________ -- ___________________________
Room Number:
__________________ Email Address: ______________________
**I, __________________________________________, have reviewed all of
(Signature)
Chicago State University telephone services and contract information. I clearly understand that
my code is not to be shared. I take full financial responsibility for payment of all calls made to
the code I am assigned.
*************************************************************************************************************
(For Telecommunications Use Only)
Room #: __________________________
Activation Date: _________________________
Student A/B _______________________
Authorization Code: ______________________
Cost Center: _______________________
Telecom. Verification: ____________________
5/20/2009